the presiding officer: the senate will come to order. the presiding officer: the clerk will read a communication to the senate. the clerk: washington, d.c, january 5, 2010. to the senate: under the provisions of rule 1, paragraph 3, of the standing rules of the senate, i hereby appoint the honorable mark r. warner, a senator from the commonwealth of virginia, to perform the duties of the chair. signed: robert c. byrd, president pro tempore. the presiding officer: under the previous order, the senate

will stand adjourned until 11:00 a.m. on tuesday, january 19, 9, >> that wraps up the pro forma session. they will come back on january 19th. the second session of the 111th congress begins on january 20th as members return to consider the nomination of beverly martin to be u.s. circuit court judge for the eleventh circuit. live senate coverage as always on c-span2. the health-care debate is very much on the minds of senators as they return to town. democratic leaders head to the white house to meet with president obama to talk about details of the final bill which is awaiting negotiations between the house and senate.

now we take you back to a discussion on long-term care services hosted by the journal health affairs and the s.c.a.n. foundation. this began a short time ago on how to pay for health care. we resume live coverage on c-span2. >> the value of any supplemental private coverage. to the extent that any public coverage relies on an insurance model, policymakers should take note of lessons learned in the private market. any voluntary public program will have to balance concerns about adverse selection against broad goals pertaining to population. premiums are no more costly--sufficient to ensure the program is accurately sound. the program must employ adequate risk-management relating to program participation,

validation of benefit criteria and more. policymakers are focused on innovative strategies that encourage individuals to plan purchased at lower ages. and models that explicitly connects public programs and private insurance coverage because of what is found in the locker room care partnership programs. wraparound projects to take hold there must be consistent definition of eligibility for private and public coverage. these are some important prerequisites for markets to work together i do want to point out that there is no consensus that in the context of the class act the insurance market will drive. some believe the program will lead to the demise of the public sector because it will be priced in appropriately. consumers will believe they are covered and need not take additional steps.

agents may find it too difficult to sell the product and the structure of the program, a long skinny development makes the development of wraparound products different. others see it as a great opportunity and argue the program will enhance consumer awareness, encouraged the development of more affordable wrap products to increase the pool of insurers and assist agents as they sell with or against the public program. clearly to maximize the chance of this more optimistic view the issues i raised in the paper need to be addressed. given the political and fiscal constraints on the expansion of publicly financed programs as well as the market forces that shape private insurance pricing neither public nor private financing approach on its own can meet the long-term care needs of all americans. in all likelihood public and private coverage will work in

tandem to mitigate the catastrophic costs associated with long-term care. public policy that supports a coordinated public private finance approach holds the greatest promise for achieving efficient and equitable outcomes for consumers and taxpayers alike. thank you. [applause] >> thank you very much. i would like to join the previous presenters in the s.c.a.n. foundation and my collaborator and a lead author on this paper. to market based in former's, taking on a tremendous momentum as a way to improve quality of care. these reforms may not be compatible with the broad goals of improving long-term care quality. in this paper we will examine what those goals are and see how to use market-based reform to

enhance those goals. long-term care policy and practice have pointed to several broad goals that agree upon goals of a long-term care quality. the first is to improve quality of life. because part of long-term care is the life and the life is part of long-term care improving quality life is an important goal for long-term care. second, the second goal is to reduce fragmentation in the financing system. the current system is fragmented leading often to discontinuity of care, unmet needs and for providers conflicting incentives for quality and cost. the third goal is to increase home and community-based care. although there is general agreement on the importance of these goals it is not clear how to achieve them. at the same time that people have agreed upon these goals

there has been increased momentum to adopt market based reform. we define market-based reform as policies that are designed to change the underlying incentives for quality didn't care. in typical health care markets little information is available about the quality of providers leading consumers who wish to choose high-quality providers with relatively little information or tools with which to do so. as a result of lack of transparency about quality providers have less incentive to deliver high-quality care or compete for consumers' based on their quality. market-based reforms are designed to increase these problems. to improve consumer decisionmaking about selecting providers and to improve quality of care that they deliver. there are a number of examples of adoption of market-based reform and long-term care most notably in public reporting and

performance. in 2002 under the employee initiative the centers for medicare and medicaid services began publicly reporting quality information on nursing-home nationally on their web site. this was followed a year later by a similar effort in the home health arena. simultaneously there have been demonstration products by medicare in home house and skilled nursing facilities. state medicaid agencies have begun experimenting with a for performance in the nursing-home setting. the question is how these current market-based reforms address these broad goals of long-term care. in theory these reforms are perfectly compatible with these goals of improving quality of life and reducing fragmentation and increasing community-based services but there are several key attributes of these market-based reforms that may limit their effectiveness in

this regard. the first limitation is current market-based reforms tend to rely on narrowly defined clinical quality measures. this tends to reinforce a medical model of care which pays more attention to clinical quality than issues related to quality of life and a crowd attention on quality of life out. second, all these current market-based reforms are set in specifics. when a consumer goes to choose a setting for their long-term care they must choose a setting and compare quality within that setting. a third limitation is the incentives are here specific can exist only for traditional providers. nontraditional care settings, these policies have not reached there yet. the limitations of current policies are problems of form and the implementation of market-based reforms.

in theory it should be straightforward to address them. one of the easiest ways to address them maybe 2 defend new measures. quality of life is one measure used in some settings but not uniformly used across existing market-based reforms. by including market-based reforms may focus attention on quality of life over the discreet -- instead of these discrete problems that are currently tied to incentives but in addition to the clinical problems we currently look at. another option may be to use broader clinical measures like hospitalization or the use of quality of care because we know these are associated with quality of life and long-term care. third option to improve measurement is to move our attention from clinical quality measures and focus on organizational characteristics that are important in long-term care. one example might be to use the measure of principles of culture

change in nursing-home. being able to reduce fragmentation is more complicated. it requires coordinating measurement and incentives across different hairs with a long-term care. this would be an important step to reduce fragmentation and enable comparisons across settings. finally expanding the use of community-based services is logistically it challenge that currently exists and requires a great deal of work. it would require developing a course set of measures across existing measures of community services and less informal ones also. this will not be easily solved logistically and requires a long-term commitment to measuring activities. it would also enable a comparison of quality across

these settings. these changes are big changes to the current format of market-based reforms but they also provide an important opportunity to use these policy levers of market-based reforms to fundamentally address the quality and improve the quality of long-term care. thanks. [applause] >> good morning. i am right between now and lunch. i want to join all of my colleagues in thanking susan and the health pares team for not only a terrific health affairs issue but for this very special opportunity to announce the launch of the long-term quality alliance. this alliance is the result of many months of work by a dedicated steering committee chaired by mark mcclallam.

this will be richly diverse founding board most of whom are here in this audience today. these are leaders in the delivery of long-term service, representative pears and purchasers of these services, family caregiver advocates. researchers and policymakers and others who have joined with a common mission and common vision to significantly accelerate quality improvement for the growing population of individuals who wake up every day requiring support for the things all of us take for granted. bathing, eating, walking, etc.. this will also focus on an invisible group of individuals to kill family caregivers these individuals rely on for help. this will foster development and use of measures that offer the most promise to improve quality in all contexts in which

individuals receive service and support. to implement innovative evidence based practices designed to achieve meaningful growth and improvement in performance. as susan mentioned i had a great fortune to serve as an adviser for this issue of health affairs, an issue that generated not just an outstanding set of papers but an excellent foundation for action. the alliance hopes to be an important vehicle to achieve many recommendations outlined in its issue. why focus? there is a demand for these services. eleven million americans receive long-term service and support. this number is expected to double by 2015 not because we are not doing a better job in prevention of disability but

because we have a silver tsunami along the way. the measures we have available to assess services and support the not capture information that is important to the vast population of consumers for whom progressive loss of function rather than making sure it is the trajectory. helping us to understand the experience of the consumers and family caregivers and their perception of quality of life. perceptions of quality of life can be tremendously influenced by the quality of long-term service and support in people's homes and community settings. services that cannot communicate respect for the individual dignity may negatively affect an individual person's quality of life. despite a major growth in the community based sector we have very few measures focused on this context. most available measures focus on quality of service in

institutional settings like nursing homes. we also have a great opportunity to impact national health priorities. among the major opportunities identified by the natural priorities partnership a group of organizations convened by the national quality forum and representing those who pay for and develop health care are the need to substantially enhance engagement of the recipients of care and family caregivers in decision making to repair coordination and promote earlier access to palliative and end of life care. this was the action agenda agreed upon by these partners to ensure high-quality affordable health care. the recipients of long-term services and support are disproportionately high consumers of costly health consumers. by targeting these priorities we expect to make a great contribution to enhancing quality and increasing and decreasing costs for all

americans. how can we make a difference? we hope to facilitate dialogue and partnership among all providers of long-term service and support and between providers in long term and acute care sectors and break down the silence in which quality initiatives trajectory occur. we help consumers and family caregivers partner with government provider agencies and others to set goals for quality. a unique feature of this alliance relative to other alliances will be the efforts we make not just to improve measurement of care but to better link practices available to improve performance in these measures and we hope to collaborate with other groups on common priorities. we want to complement and leverage and advance a number of initiatives you heard about today both public and private targeting this population. in the long run we realize organizations that provide long-term service and support must have adequate quality and financial incentives to continue to improve quality.

we will use what we learned to assess policymakers in designing popular incentive is. what are our short-term priorities? clearly advancing quality indicators that are important to consumers and family care givers is a top priority. we need measures that are respectful of and responsive to these individuals's needs and values. you heard from carol and others that improving care transitions is exceedingly important. among the population of people with serious disabilities, transitions in health and health care are the norm. episodes of acute care resulting in frequent hospitalizations are very common and much of our data on this is from the nursing-home population but in a six months period one in six nursing home residents are in the hospital. 40% are active in care during 30 days prior to death. within the broader population of those receiving long-term service and support living in

the community 40% will be hospitalized each year. these hospitalizations are disruptive and fraught with complications and frequently associated with poor outcomes. accelerating cognitive decline and medical errors and affordable hospitalization. individuals receiving long-term service and support are especially vulnerable to the failures in our current system. lack of transfer of information, poor communication between family members and others, inadequate preparation of staff in acute and long-term sectors to address the needs of these people. we have lots of opportunities here. high risk of affordable hospitalizations are major outcomes as a result of these. available data suggests between 25%, and 40% of hospitalizations of elderly long-term care recipients are avoidable. decrease in health-care costs is a major goal of the alliance. in addition to the tremendous

human burden associated with use of hospitalization these hospitalizations have been associated with rapidly escalating cost. the estimated savings in hospital costs of medicare for nursing home residents range from 1.1 to $1.4 billion. our strategies are as follows in the short term. to set meaningful goals for achievement of family center care to improve care transition, work toward preventing avoidable hospitalization and we expect to focus on these goals over the next two years to identify and disseminate effective practices to improve performance and create the incentive to award performance. in summary improving care transitions the addition to reducing hospitalization and decrease in health-care costs for this group are essential if we are to substantially contribute to addressing national health priorities. these short-term priorities have the additional benefit of placing a spotlight on a growing population of people who need

much more attention locally, nationally, and reform efforts. these individuals deserve long-term services and support that meets their definition of quality. we have a huge opportunity to make a major difference in the lives of millions of americans and we plan to capitalize on the ideas generated in these great papers today upon many of the leaders presented here in the audience as well as others to make the most of this moment. thank you. i should mention there is a press release on the alliance out at the table. we welcome your taking a copy of that on the way out. thank you very much. [applause] >> in addition the alliance is holding a press briefing right after this session just across the hole at the press club. conveniently situated for all of you who would like to find out more.

just a quick question to start with. to take us back to robin's discussion about work-force, where is the quality of people in the work force on the  alliance's the agenda and the investments she and others said needed to improve the quality of that workforce? >> absolutely no question that we will not achieve the quality, standards of care we need without investing in the workforce but setting the benchmark is the first step to recognizing where the gaps in quality are and what investments need to be made to address them. there is an intimate link between work force and the work of the alliance. >> we will open this to questions or comments from all of you. let's take one right here. >> gail hunt. i have a question for mark. with regard to the middle class

uptake of private long-term insurance can you comment on the success or failure of the federal long-term care insurance policies that were offered? the massive campaign to reach federal employees? and the public awareness campaign that aspy and aoa have been doing about know your future and those have gone to middle-class people. can you comment? >> i have the advantage of having some of my coauthors here. i will let eileen talk about the and your future campaign. she has been intimately involved in that. it depends on what the definition of success is. by all measures the growth of

the market has been less than what optimists as well as pessimists thought it would be at this point. it is clear that with suitability rules that have been put in place where unless you have a 7 level of income and assets you are not considered a suitable purchaser, you will be going after higher income people. the take a break, we have john cutler here as well. maybe he could comment on that. it is still considered to be the largest group out there. i don't know what the benchmark was for with the red is successful or not in terms of penetration. i will let john answer that question. john was intimately involved when that program was set up. >> the federal program is a

group program. we have the same 5% that most employer groups have. as an insurance success story i would say it is but as a public policy matter mark is right. private insurance sales have not been where people want. i also have eileen to answer that question. >> below in your future is still -- sorry about that. educational campaign oriented broadly towards long-term care planning. it was designed specifically to address all demographic segments among long-term planning including those with different financial needs, those currently receiving services looking at housing and insurance and finance service delivery and selection. was not just about insurance. we did achieve the goal of

reaching a diverse group of people. individuals aged 45 to 65, there was no exclusion. we saw the ex bans -- the planning kit and the long-term care and those that did not being pretty similar demographically, particularly with respect to income. we did find that people who got this planning guide were twice as likely to take this planning action which was defined broadly not just by buying insurance but talking with your family about your needs and wishes, talking with an agent or financial planner about long-term care. looking at existing health-care coverage to see if it covered long-term care because that was a wake-up moment for many

people. thinking about your housing needs as you get older. when the initiative is more broadly defined and more affordable planning is not something that needs to take a lot of money. for you see more representation in the response. >> do we have any other questions? let me ask a couple more. one of you, rachel. you reference the importance of making information available for consumers in a greater degree to enhance their ability to make smart choices among providers. we have the example of nursing-homes up and running. you suggested in your paper there's a lot farther we could go. what would you say is an ongoing transparency agenda in long-term care and if you were giving advice to mary in her capacity

in charge of the quality alliance, what do you suggest is the transparency agenda for long-term service and support? >> there has been a struggle in the public reporting arena to make information useful to consumers. consumers generally are very happy to have information available but very few people seem to use information. the nursing-home has made very specific efforts to make the information more accessible. they recently instituted a five star rating. a large array of quality measures including in nursing-home compare into a single rating of a star system. there is a lot of work that needs to be done to improve the way we create these overall summary measures. that is one area that deserved a

lot of attention. making information relevant to consumers when they are looking to choose a long-term care setting and facility, really important research agenda that has not been fully addressed. there are a lot of complicated issues about summarizing them and allowed of people doing really important work on how to make the information more relevant and more salient to consumers but there are opportunities to try to allow consumers to identify the areas of care that our most important to them and more flexible display of information that highlights those areas. ..

could there be some comply 10 tri, the entire focus of the piece you coauthored? how do you think we move forward as a country to address some of the polarities that really don't make much sense given magnitude of the issues we need to address? >> i'm hoping even though i'm an optimist and not this crazy, you know, that the

paper we put together really tries to address that point. you know, i think we've too much been focused on the issue of, what should be central here, the private sector or the public sector? that doesn't make a whole lot of sense. i think the most important thing, is that, you have the, and there are examples, actually of programs, public and private programs, working together, the partnership is a good start in that direction. boy, it took a long time in their, the original, i don't know if the word is godfather, mark miners i saw earlier is here. he has been working on this close to 30 years. it takes a long time but you have to have people sitting together at table to make these things work and it's clear, i think, to everybody that when we're talking about solving a national problem, there is just not the capacity for either sector to kind of work outside or not work in

tandem with the other. that is the point we tried to make in the article. suggest some ways of doing this. but you got to have people sitting around the table. >> well, wonderful note to close on. and i would say we at health affairs hope all of you sitting around the table will have a copy of health affairs handy. particularly all of those in the audience who worked so hard on these issues for so many years. as well as our authors and others who contributed to our ability to bring this to you. thank you so much. please take a copy of our redesigned journal with you. give a copy away to your friends. thanks again to all of you. thanks again to bruce chernoff and the s.c.a.n. foundation for all their support. this will not be last salvo of long term support affairs. we have a renewed commitment to keep this going forward and we hope many of you will be contributors to help us doing that thank you very much, enjoy the rest of your day. [applause]

[inaudible conversations] [inaudible conversations]

>> later today, president obama will announce new measures to tighten up airline security, after the failed christmas attack on a u.s. jetliner. the president is expected to make a statement at 4:00 p.m. eastern. we'll have that for you live on c-span. the president has scheduled a high-ranking white house meeting this afternoon with 20 government officials who have been tasked with carrying out reviews following that botched attack. also, the health care debate resumes in earnest, today, rather after morn than a week of quiet following senate passage of its bill on christmas eve. the four relevant house chairman will meet with speaker nancy pelosi and her leadership team this afternoon in the speaker's capitol office to start setting parameters for negotiations with the senate. the house speaker, nancy pelosi and house majority leader steny hoyer will head to the white house for an early evening meeting with

president obama to discuss the final bill, according to democratic officials. coming up in about 25 minutes, at 1:00 eastern, press secretary robert gibbs will hold a white house briefing and we'll have that for you live here on c-span2. in the meantime, a discussion on national security issues from today's "washington journal.". >> host: evan peris of "the wall street journal" rather joins us to talk about terrorism and homeland security. the president is scheduled to meet with his national security team this afternoon and make announcement later on in the day. who is meeting with, what are they talking about and what is he going to say in his announcement? >> guest: there are about 20 officials who are responsible for various parts of the national security apparatus and they range from director of national intelligence, cia director, fbi director, justice department, the attorney general and dhs, it runs the gamut in. he is bringing them all in.

as you know they have turned in some reports over the last couple days, essentially, sketching out what problems they found inside their agencies, and, how they plan to fix it. i think the president plans to basically go over those reports and find ways, you know, perhaps dressing down a few of those. >> host: that sort of goes to my next question. is this going to be a meeting where he is mostly listening to his cabinet members and his advisors or is he giving marching orders in this meeting? >> judging from what i understand is in some of the reports, i would expect that the president might do a lot of talking. you see what's happening is a lot of the agencies are pointing fingers at each other and in some cases, asserting that they have, that you know, the system worked, at least their part of the system worked and, perhaps not a lot of taking the blame for themselves is going on. so i think the president

might end up doing a lot of talking this afternoon. >> host: is it fair to describe this as a coming to church meeting? >> guest: come to jesus moment, exactly. >> host: and then, later on he is going to give announcement, a speech about revisions in homeland security, what do you think he is going to be saying? >> guest: i think what he is announcing is more security measures and more ways they will improve the different agencies speak to each other. there is obviously, there were some major failures in the way the agencies were sharing information. that has happened repeatedly. most recently in november when the shootings at fort hood happened and we found out that there were some intercepts found by the nsa and fbi that weren't acted upon. this is obviously is a bigger problem than anybody realized. i think the president will try to address some of that. >> host: terrorism and homeland security is our topic for the next 45 minutes with evan perez, of

"the wall street journal." if you like to get involved in the conversation, 202-7070002 for democrats. independents, 202-268-2065. send us messages on e-mail or twitter. this announcement the president has this afternoon will he reach out to countries oversees and trying to enlist them in making the decides united states and in fact the world safer. >> guest: the president since he came to office has been trying to sound that theme. he traveled overseas, trying to, at least, at least make, make the words that come out of the president be about more cooperation and so on. and i think he is going to try to incorporate this theme, which is, you know, the concern about terrorism and, perhaps something that, has been gone into the background, under his presidency, until now.

he is going to try to merge those two things and you will probably hear him talk about cooperation overseas to help make everybody safe. >> host: let's go to the phones. our first call comes from jacksonville, florida. william on our line for independents. good morning. >> caller: good morning, sir. good to see you. i like you. you're pretty informative. hello? >> host: go ahead, william. >> caller: yes, sir. how do we fight an enemy that don't wear no uniform, number one, the terrorists? that is the crazy thing i ever see. can nobody speak the language over there? can nobody go to yemen or afghanistan and, them peoples -- you know you're not from there. you're hooked up with -- over there my second question is, why is britain and all them other places ain't on terrorism list? i want to take your answer. y'all have a happy new year,

guys. >> guest: the question of, fighting a war with an enemy that is not wearing a uniform is something that is obviously been a big topic for the government since 9/11. the bush administration handled it one way. the obama administration is pretty much also of the view this is a, it's a war, you know, and whether someone is wearing a uniform or not, it is a war is the way both administrations approached it. they have had some differences over whether or not they should use certain methods and certain systems like military commission systems but, i think, both administrations view this as perhaps a war that is going to go on for a long, long time. and that it doesn't matter whether this, you al qaeda and other extremists are wearing a uniform. it is a war. >> host: the caller also mentioned tighter security measures at what the state

department has listed as high-risk countries. those countries include, afghanistan, algeria, cuba, iran, and iraq as well as lebanon, libya, nye dpreer i can't, -- nigeria, pakistan and saudi arabia. somalia, sudan and syria and yemen. go ahead. >> guest: well, i mean those are some countries that have been picked out specifically for further screening. there is a lot of criticism of that because, as you know, the last time an incident like the one that happened on christmas happened, was richard reid and in 2001 and he was a british, carrying a british passport on a flight into miami. if you were to put aside people from nigeria and somalia and so on, and focus on those people, you probably wouldn't have picked up on richard reid which didn't happen. so, you know, i think there is valid criticisms of what

exactly are we aiming for here? i don't know that the administration has explained that fully. >> host: next up, is washington, missouri. paul on our line for republicans. go ahead. >> caller:, yeah, i was just calling to talk about the security that we have. i think that napolitano, eric holder, and president obama have not a clue what's going on with these people. i think that, you know, if you look back and you see eric holder before he became attorney general was working in a law firm that did pro bono work for the terrorists, and so that just goes back to tell me they don't have a clue and they're not going to make the effort to make us safe. they think it is a joke and, good luck, america. >> guest: well, you know, eric holder worked for a law firm that, like many big law firms, volunteered some time

to represent some of the detainees, the war on terrorism detainees. there were a lot of legal issues raised after 9/11. so his law firm was like many other big ones that did do some of that work. >> host: in baltimore sun this morning, obama set for security review. they right they're going to be talking about the addition of more names to the government terrorist watch list and no-ply lists came after u.s. official as larger database of suspects terrorists. intelligence officials said mon, people on the watch list get additional checking before they are allowed to ender this country. those on no-fly list are barred on entering aircraft in or headed for the united states. how are they going to make that determination that more people are going to be going from the terrorist watch list to not fly list? is there a specific set of criteria? >> guest: there is a specific set of criteria.

the question obviously people who are skeptics like i am, would ask is, you know, how did that happen? how did it suddenly become, that dozens of nails are being moved over from one database over to a more stringent database? why didn't that happen earlier? you know, what new criteria, what new information have you discovered that made, that made you move those people's names over? is it just political issue? you're trying to basically cover all the bases and so on? i don't think the explanations of what exactly occurred have really been forthcoming from the administration. i think a lot of people should ask the questions of what exactly, what the criteria were to be able to move those people over. >> host: next up, is virginia beach, virginia. on our line for democrats. good morning and welcome to the "washington journal.". >> caller: good morning. >> host: go ahead, ma'am.

>> caller: i'd like to comment on the homeland security. i think there is a break and there's probably some terrorist activity in our homeland security. there have been too many people to get, infiltrate our country and to infiltrate handshaking with the president for it not to be an inside job. that needs to be addressed. now, fly a lot. it unnerves me that i've seen a lot of lax security as they practice universal precautions for health care, i think they should do universal precautions for terrorists activity. everyone should be treated that way until otherwise notified. >> host: ma'am, are you still with me? >> caller: yes, i am. >> host: as a frequent flyer what do you see that could be improved in terms of securing the airports and making sure that everybody who is traveling is safe? >> caller: i have seen, this is myself, i have carried

aboard some liquid, it was perfume and lotion. no one questioned me about it. it was, it wasn't regulation size. and i got away with it. and, i wasn't trying to. it was in there by mistake but i got away with it. and i have no, i have no plan to do anything wrong to anybody. but just as, me as an individual can get away with it, hundreds of other people gotten away with it. and i am randomly searched sometimes but i fly too much not to be searched often. i fly at least, gosh, i fly all the time. i lose track how much i fly because i have to work out of town. there are things that i see really need to be cracked down on. i am very much in agreement with the scanner. >> host: thanks for your call. >> guest: i think she's, the caller is pointing out something a lot of people are saying which is the system is very imperfect and there's a lot of, there's a

lot of, lapses that happen. it is clear also that, you know, i talked to, for example, a former senior official in the government who told me that, he and his family were detained at the airport, searched, simply because they found he had traveled to afghanistan. now that person is searched and, scrutinized but then other people are not. so there is clearly some ways to improve the system. >> host: we're talking with evan perez of "the wall street journal" about terrorism and homeland security. and also the president's meeting this afternoon as well as his announcement later today from the white house. our next call comes from bryson city, north carolina, on our line for independents. justin, go ahead. >> caller: good morning, gentlemen, how are you doing? >> host: just fine. >> guest: good morning. >> caller: the reason i'm calling because i was watching mr. brennan's interview yesterday on "fox news sunday" and he had mentioned there were no

upside nor downside to trying these individuals in criminal court or military tribunals. what he said the administration is trying to keep flexibility so they could make their plans accordingly. my question is, doesn't that statement imply there is upside and a downside, one or the other on an individual basis which would be determining factor whether these individuals are tried in one way or the other? and the second, what is ever the upside of keeping terrorists off our soil first place and holding them somewhere else? >> guest: well, on first question, i think you've put your finger on something that the administration, this administration is struggling with, which is how to explain why they decide to put some people on trial in criminal courts and civilian courts and why some need to go to military courts. the fact remains i think, they don't have a good answer because, because they're really stuck. the administration prefers

to use civilian courts. they were very critical the president was very critical of the bush administration and military commission system. then you get into office and sees the evidence that the government has against some of these detainees, and realizes that, you know, some of the evidence probably could not hold up in, in civilian court. so that is what he decided to basically go back and rejigger the military commission system. and that is something that, essentially the administration doesn't want to, essentially put out there. the fact that, you know, the military commission system is different and in some ways a lesser system and, and, it is internationally viewed that way. that is one reason why you see them struggling to explain why they decided to go one way on some detainees and the other way on the others. >> host: we've got this twitter message from republic first, who writes, how much of national security is outsourced to a

corporate contractor, for example, the cia or border? do their employees have security clearances?. >> guest: yeah, very common. a lot of, a lot of what the cia does, a lot of what dhs does, is done by big companies, big contractors. billions of dollars that are spent on this, on this stuff. and a lot of these people are people with security clearances that they had when they were government officials and then they go over to the private sector and make a lot more money, and carry their top level clearances with them. >> host: one element that's come into the news lately is that tsa or, some of the employees of tsa are trying to organize and, go into a union, or form a union. how much of a factor is this going to be in the debate regarding homeland security in the next, in coming weeks and month? >> guest: it depends. for the republicans it is a big issue. as you know, this has been

an issue since tsa was createdded. since the homeland security department was created. there is a big issue, big divide politically between democrats and republicans on this i think republicans will try to make an issue of this, will try to point out they think that this is not safe. democrats will argue, probably a little more quietly, that, people should have a right to organize and have a right to, just like anybody else. >> host: michigan, brian on our line for republicans. >> caller: hi, thank you. going back to the first world trade center bombing i was just amazed at the lack of scrutiny put on the clinton administration when they turned this into so-called criminal matter and we all know what happened in the 0s. the fallout from that, embassies the cole and a lot of other things we've already forgotten. i can't imagine we're going

back to that type of system. president obama, who i am trying to support, i really am trying, he says that, he's worried about our image overseas, excuse me, but, in fact, when this major, who should have been booted from the service, no doubt that is the army's fault there, prior to him doing the damage, the murders that he did, he is worried about image but comes out right on tv says this man is going to be tried and found guilty. now how was that played out in the arab world? you know that was just parsed out and it was ridiculous statement. i'm sitting with my mom, who is still, she is in her 80s and looks at me, what do you think of that? i said, i think that was about the dumbest statement that i ever heard a president make. and again, i'm still trying to support him. these things don't square up. now president obama made a lot of campaign promises and he is still trying to appease his democratic party by, he stated, categorically

that he wants to close gitmo, close gitmo. i'm sure, deep down he wishes he would have never made that statement. >> host: thanks for your call, brian. >> guest: i don't know what, what comment the caller is referring to. i think obviously there's a lot of, the president has been out there, you know, trying to figure out a way to make the peace on the issue of muslims in the u.s., and, i think that is one of the things that they're trying to focus on. >> host: there's an editorial in this morning's saudi gazette, that responds to the president's announcement to tighten security. it says the new procedures are clearly discriminatory, bordering on ethnic profiling. obviously the vast majorities of nationals of those countries which include saudi arabia and those passing through those countries on their way to the u.s. harbor no ill will toward the u.s. and have no intention of causing any harm whatsoever. the same can be said from those from the rest the

countries around the world which is why the new procedures are so unfair. the editorial goes on to say, no one, not nationals on the country on the new list or nationals of any other country is likely to object to enhanced security measures. why not allow of us squall standing in the fight against terrorism and submit all of us to the system procedures? >> guest: a question a lot of people are raising which is, you know, if you decide to focus on these 14 countries and nationals from these 14 countries or people who travel through these 14 country, then perhaps might you be missing other things? which from our experience, shows you is something that is a very real problem. and i don't think that the administration is fully explained what exactly went into this decision. whether it is just a temporary measure or not and whether or not there is something longer-term planned to deal with this. >> host: and is it just nationals who are flying from these countries, or using thee countries as a country of origin, or, if

they pass through, let's say like the christmas bomber who passed through amsterdam, would he be subjected to more skrut news security measures in amsterdam as well as the country he originated from as he was flying to the united states? >> guest: right. the idea anybody originating from or traveling through. so if this flyer, this, if the alleged bomber had gone from, say, lagos, to dubai, to, to amsterdam and then onto the u.s., he would have been subjected to the same scrutiny because of where he originated from. if he gone through, if he had originated somewhere else and gone through saudi arabia, for example, that scrutiny would be there as well. >> host: back to the phones. orangeburg, south carolina, mary on our line for democrats. welcome to the program. >> caller: good morning. i have a couple of questions. one is, number one, i don't understand, when did all

this start? what did we do as americans so bad that the islamic world, you know, so against us? i don't understand that part, what did we do, as far as making them hate us the way they do? and the second one, i have to say, could you, explain something on about when 9/11 happened, from what i can understand, that the bush administration had intelligence on an attack on america five months, and he did nothing about it. and went on vacation? so could you verify if that was true or not that he did have five months advance intelligence saying that there was going to be an attack here in america and he did nothing and the next thing i wanted to ask, is it, possible that, if something can be done about these republicans, they just keep on talking about president don't know what he is doing, when i think he is doing a good job according to what was handed to him, as far as,

you know, left over from the bush administration. and that's my comment. thank you. >> guest: regarding the bush administration, i think that has been a something for debate. there was some intelligence that the government did have that indicated something was going on. cia knew that at least a couple of the hijackers were in the country. and, knew they weren't supposed to be here or were suspicious about them. and, did nothing about it. so there's been a lot of debate over how much knowledge rose to the level of the president and the white house, and i don't know that, that that, anyone really knew something was coming on that day and the extent of it, to have done anything to stop it. >> host: next up, logan'sport indiana, on our line for independents. good morning. >> caller: good morning. i like to talk about the

definition of terrorism and terrorists. the root word is terror. terror is extreme fear. extreme fear to this country, has not only lost the people who have been killed by the terrorists acts, which is just the, the, head on the nail, it is also affected our economy, our paranoid, paranoia of our citizens who i remember were out, after 9/11 buying plastic and duct tape, and, they have also, terrorists have also made us go to war with them, and send our troops, who our citizens, over to the majority of our enemies who every little person who has, has hate for us, has a chance to kill more american citizens, and i just, i just, don't understand where this is supposed to stop, and what war on terrorism the,

the final goal, for winning the war is? >> i don't think this administration or the previous administration really knows where this is going. nobody knows where this is going to end. i mean there is different ways to address this. but really, even to address what the previous caller was talking about, i mean, i don't think there is any explanation, any explanation for what the origins of this is. people try to cite the troubles in the middle east, palestine, occupation, and so on but really there is, myriad reasons and no reasons. in "the financial times" and others -- al qaeda seeks to make yemen its safe haven. explain to us what they seem to be moving there and tell will shift the u.s. response to the war and terror? guest: it is like water. if fines -- always finds a place

to go. @@@@@@@ @ @ @ on the line for republicans. caller: i just wanted to see what your views are. i think it is ridiculous when we can read where the british citizens, mousavi was a french citizen -- al qaeda is not the next person isn't going to -- the nigerian boy was radicalized in london.

it's not the poor, fanatics in this country that are going to get visas to come to the u.s. the next person will be someone from europe or even domestic terrorists that are going to do something. and just labeling certain countries, i mean, maybe some countries in the middle east. i guess it's reasonable. but just labeling countries and saying that, oh, you know, people coming in from nigeria are going to be patted down. i don't think it's going to make any difference. and al-qaeda keeps changing their techniques and tactics. i think, you know, not addressing the issue of radicalization in europe, in france, in spain, in italy, in england is going to cost us down the line. that's just my views. thank you. >> guest: i think the caller points exactly to -- i mean, she encapsulates what a lot of people are saying and the problem is if you focus on certain countries, then you might be missing other things.

if you remember, just before this event happened, before the christmas day attempt, we were having a lot of discussions in this country about radicalization in this country because there have been a spate of incidents involving either people who were u.s. nationals or people who had permanent residence here in this country who were radicalized by the internet with some of these imams. if you just focus on people where the last attack came from, then you're going to miss where the next one will come from. >> host: evan perez is the "wall street journal" reporter who's joining us for a discussion on terrorism and homeland security. he's the justice department reporter for the "wall street journal" and has been so since december of 2006. previously, he started at the "wall street journal" back in 19 a 98. worked for the journal in miami and most recently covering the airlines, aviation and hurricane katrina. lakewood, colorado, kayely on

the line democrats. go ahead. >> caller: thank you so much for taking my call. i would just like to speak to the issue of politicizing terror. now, we have heard people from the republican party wishing that obama would fail. holding nazi signs. and we have nationalists, socialists in germany that used the idiom that liberals are weak. and they use it very effectively to down trod the jews and here in this country, now we have dick cheney saying that this president does not understand that we're at war. this is just absolutely so unacceptable in my opinion. now, the simplest explanation is often missed. the cia knew about this young man that was going to board the plane. why didn't they report it?

i just wonder if this person is working for dick cheney. that's the simplest explanation. >> guest: well, i mean, the political angle of this has been quite surprising especially some of the charges and counter-charges that you see going on. i don't think there's much substance to a lot of what has been said in the past few days except that obviously people are looking forward to the 2010 elections. and so what the caller is pointing out to is perhaps some of the failings that the cia and the state department and other agencies, the national counterterrorism center perhaps have to explain. but to sort of find some kind of political motivation behind those failings or, you know, some of the -- some of the responses is perhaps reaching. >> host: eugene robinson has an op-ed in this morning's "washington post" and he questions why cuba is on this list and writes there is no

>> guest: well, you know, i lived for a long time in miami. miami is probably the reason why cuba is still on the list. it's a very big population of cuban exiles in miami. they are very politically active. they're very, you know, listened to by previous administrations and this administration. and i think, you know, there have been some incidents in the past in which the castro government has supported things that we would consider terrorism

or what certainly people in miami would consider terrorism. and so that's one reason why they're on the list. and, you know, until relations really improve between us and cuba, i don't see the u.s. removing cuba from that list. >> host: do you think it gives the administration an opportunity to say that they are not just picking on countries in the middle east or countries where islam is the predominant religion. they can say, well, we've got cuba on the list as well. >> guest: well, i think what they did is they decided -- they looked at the state department list, which includes syria, it includes iran, it includes north korea and cuba. and it basically -- and they basically decided that they were going to use that list 'cause if you remove one, then politically you're going to get attacked. i mean, in miami, you're going to get attacked at why are you treating cuba separately and differently when they are declared a state sponsor of terrorism. if you remove any of the other countries. so i think there is probably some of that, but i think that the simpler -- the simpler explanation is probably true.

>> host: staying on the topic of state-sponsored terrorists why do you think north korea is not on the list? >> guest: that's a good question. first of all, there's not a lot of flights that go through north korea. there's not a lot of, you know, air traffic that is allowed through. so, you know, that probably, you know, is something that's not going to -- that's not going to be a problem. i think that's a good question. it's a good question if you're going to use that list, then use it. >> host: jacksonville, florida, patrick, on our line for independents. you're on the line with evan perez. . >> caller: good morning, mr. perez. >> guest: good morning. >> caller: i mean, i'm not trying to be funny, but are you really just educated to understand that cuba is on the list because of all the other

noncomcompliance or not complying with what the united states wants because the united states gets what they want. i'm a terrorist and all the united states citizens are terrorists. are you there? >> guest: i'm here. >> caller: go ahead. >> host: no, he's gone. >> guest: what i was pointing to is the -- is the political nature of this. i mean, cuba is a big issue especially in florida where i lived for a long time. and so, you know, it's something that, you know, is always going to add a few complications to something like this. i think the government -- the administration certainly looked at this and decided to go the safe route and add cuba in there. >> host: what's the difference between a terrorist watch list and a no-fly list? and why wouldn't they just put everybody on the terrorist list on the terrorist watch list on the no-fly list? >> guest: you know, that's a good question.

i think there's been a lot of -- a lot of examination now of exactly what these different lists include. the way -- the way the government explains it is, there's a larger database, which has got 550,000 people on there, or names of people on there. some of the more double names, some of them are aliases and so then. some of them are people who the government has been -- has talked to about different terrorism investigations and then from that they decide to get a more narrow list which includes, you know, a few thousand people who are banned on flying on any planes to the u.s. and which is used by other countries, too, by the way. and then there's other -- other lists that are -- you know, people who are selected foreclosure scrutiny for more -- for interviews, if they present themselves at the airport. or, you know, if they try to buy a ticket or so on. so the government has basically

all these different lists. and right now i think what the government -- what the administration is trying to do is trying to figure out perhaps a streamlined way to move people back and forth or, you know -- to make sure that the right people are on the list that are at least, you know, selected for scrutiny. >> host: how much discussion this afternoon that the white house is going to involve upgrading the technology, particularly, the body scanners and those puffers? >> guest: i think a lot of that -- a lot of that is forthcoming. you'll probably hear from the president and the administration if not today in the next few days. that they're going to spend probably billions more on new technology, probably new technology -- new computers for the counterterrorism forces -- sorry, agencies for them to be able to collate this information better. that comes in. i think you're also likely to hear a some more spending on body scanning technology and perhaps new technology that they

haven't -- that we don't even yet know about. >> host: next call comes from rock island, illinois. bash on our line for republicans, go ahead. . >> caller: good morning. i think basically everyone should read the book "horse soldiers" and they would probably understand more the country over there as well as what our military is going through to try and help and maintain because it's like -- there's a pocket here, a pocket there, and the terrain is horrible. then they might understand, too, why the people are coming over here. and there are individuals that have been so brainwashed that they feel the only way they can get to heaven is to kill people. which is a sad, sad thing. but anyhow, i do believe that's a good book. it explains not only the terrain but the mindset of the people there. and the tradeoffs that have to be made.

>> host: are you familiar with the book? >> guest: no, i'm not. i'm not familiar. >> host: let's go on to silver spring, some had misdemeanor then. -- maryland. >> caller: good morning, america. i love this country with all my heart and it distresses me that we're so divided. i sincerely wish that for 2010 we will somehow find a way to get together as americans. because president obama, like the rest of us, love this country. i have two specific questions for your guests. my first question is, if i'm walking in a secluded area and there's a pussycat behind me i'm not concerned. if i turn around, there's a lion behind me i'm going to be concerned. i wonder what's wrong with the profiling. that's my first question. and my second question is, it seems to me -- i'm on airplanes all the time. my wife lives in another state.

so every weekend i'm on airplanes. i think that the tsa and these other agencies do an excellent job and i feel very safe flying on planes. as i say, i fly almost every weekend. but my second question is, it seems as though we're always fighting the last battle. you know, now you can't put pillows on your laps or blankets or whatever. i wonder. is there some organization or some agency or some room, some think tank where people are imagining what would happen -- i mean, for example, i can imagine people secreting explosives say breast implants or something. how would you prevent something like that. i'll take your responses off the air. >> guest: fighting the last battle. it's a huge problem. it's partly of what has happened here. in 2006, if you remember, there was a plot to put -- to bring liquids onto planes and explode them as explosives.

and, you know, we had known -- the government had known about such plots for a long time before that. but it's only until there was a specific plot that they decided to roll out these new procedures whereby you couldn't -- you had to bring in just a little bit of liquid, 3.2 ounces i think is what it is. it's a constant refrain. i think the government is set up that way. and that's the stance it happens in the past administrations, this administration and in future administrations. it's a reluctance to do too much because of the privacy concerns. the other thing that the caller just raised, which is profiling, if you talk to people in the national security arena, i think a lot of them will tell you that perhaps our country should relax some of its expectations on privacy. people at the aclu would strongly disagree on that.

a lot of people think that profiling doesn't work simply because it gets you focused on the wrong things. and doesn't really allow you to think about -- you know, outside of the box of possibilities that maybe you haven't encountered before that go into your profiling. so i think it's a big debate that is probably forthcoming on this issue of privacy and the issue of profiling because it's something that i think we're struggling with constitutionally and actually culturally, i think. >> host: in the meeting later on today, with the president, who will the president point to not necessarily to blame but who does he see as having the most responsibility for the attempted explosion on christmas day? and then who will he expect to shoulder the most important in this new step in front homeland security, this new phase? >> well, i think the president -- there's plenty of blame to go around.

that much is clear. i think he'll look at people inside the -- you know, the director of national intelligence. you'll look at people who are running the national counterterrorism center. the cia certainly didn't do some things that it should have done. and the state department, i think yesterday i heard -- i saw some comments of secretary of state clinton who was defending the behavior -- or the actions of the -- of her agency. i don't think -- i think it ms. some of the point. i think, you know, people are wondering if the father of the alleged bomber comes into the embassy and gives these specific concerns that he has about his son radicalizing and yet you don't cancel the visa, there's clearly something wrong there, you know. it may have been not the procedure that you followed at the time, but certainly you can admit that that should have been done. >> host: is anybody going to lose their job over this?

>> guest: that's a good question. the recent history indicates that that is not the case. people don't lose your jesus. -- jobs. they just vow to do better next time. >> host: our our line for independents, gary from brian, ohio. go ahead. >> caller: hi, guys. i was just having some thoughts here. and as far as the security goes, what would be wrong with the plan where we would have maybe six major hubs around the world where flights into the united states would originate from? and have americans assume total control of those six positions. it would seem to me to have a lot more control over who's coming in. i'll take my answer off the air. thank you. >> guest: i think the airlines would tell you that's not workable. i mean, obviously the world economy depends on free movement of people and goods and so on. the u.s. setting up security people overseas, now that's something that's already being

done in some places in the caribbean, for example, in cancun and i believe in jamaica and places like that where you have very high tourist traffic. there is some screening allowed on the shores of other countries. in europe and in other countries, i think you'd get some resistance for sovereignty reasons.nñy i mean, they don't want americans doing something that they believe they have the capability to do. >> host: the subhead >> host: having enough people on the ground to do these security checks. >> guest: yeah, i think a lot of them just didn't understand what exactly was the -- what were the new requirements. i think there were airports in france and in the u.k. where they didn't know whether the rules that the u.s. was now trying to promulgate were legal in their system.

and i think there is a general -- this is a problem most countries have, which is these are not jobs that you're going to pay a lot of money for. the screening jobs i'm talking about. and so, therefore, you attract a certain level of candidates, job candidates. and that all follows from there, you know. it's sort of whether you want tr pay the money to be able to increase security. >> we see summits all the time with leaders of various nations, economic summits. we recently had the climate change summit in copenhagen. any thoughts by this administration or any a of his counterparts overseas to having some sort of antiterrorism summit in the near future or in the future? >> guest: you ñknow, there's ben some speculation on that front. the u.k. -- sometimes summits come as a result of leaders who are in trouble.

so you might have, you know, somebody in europe -- to host some kind of summit to be able to bring all these leaders forward and show that they're doing something. >> host: our last call for evan perez comes from segoville, texas, james on our line for republicans. go ahead. >> i'm wondering why we're so concerned about the air traffic  if i were a terrorist i would hop a ship and go to latin america or canada and really do some damage. i can't7(w believe that they do do something about our borders before they start all this crap about the air traffic. i know it's the fastest mode of transportation but the surest way would be like i said. and another thing, why are you having so much democrats calling in today? i've watched you for years and you've usually tried to have it pretty well balanced but you haven't today. thank you. >> host: sir?

>> guest: well, i mean, i think the caller is pointing out to, you know -- our governments not thinking outside of the box. and i think it's a good question. i mean, as to whether or not people can come from other places. i mean, there'sw3h not been any attack that has come forward from -- certainly from the south. there have been plots that have come from -- through canada. so maybe we should look north as well, not just -- not just south. >> host: evan perez of the "wall street journal," thank you very much for being on the program. >> guest: thank you. >> a live look at the white house briefing room where press secretary robert gibbs is expected to conduct today's daily briefing in just a few moments. scheduled to begin at this hour so we expect to see the press secretary shortly and we'll have it live for you here on c-span2. until it gets started more from today's "washington journal."vt

talking about a proposal by the irs to start regulating paid tax preparers and want to get your thoughts on that. our first call comes from elmhurst, illinois, mary on our line for democrats. >> caller: hi. i think the problem it's complicated. the forms have gotten more complex.6@b and a person should be able to do it themselves and not have to count on somebody else to prepare their taxes. it's ridiculous to expect every person to have to go to a tax preparer. >> host:r mary, do you do your own taxes or do you pay somebody to do it for you? >> caller: i pay somebody. and they charged me an awful lot last time also. i have a family trust situation so i don't dare try to do it myself. >> host: and how much did you have to pay? . >> caller: well, my -- my taxes? >> host: no, no. >> caller: i paid the man $900. it was a company.

that was really outrageous. >> host: $900? . >> caller: yeah, i was shocked. it was $500 the year before. >> host: so you've had to pay people on more than one occasion to do your taxes? >> i don't trust myself to do it. >> host: and are you using the same person over and over again? are you confident in their services? . >> caller: they're competent they do well what i need to do. i need several kinds of papers. i need different forms. lots of information to go to them. it's complicated. >> host: would you feel more comfortable if you knew that they were regulated and had to pass some sort of test to be okay'd by the irs? >> caller: they're competent.rfñ i'm not worried about their competence. just charged too much. >> host: let's go to richmond, virginia, charles.

you're on the "washington journal." . >> caller: yeah, good morning. i think this is the best thing i've heard in quite a while. i've actually seen a paid tax preparer take a person who filed a short form and actually on some tax forms all you got to do is put certain figures in there, sign your name and send them in and you don't even have to do the math. i've seen some of these people do that. and usually it's people -- poor people who have a high school education, who have got a menial job and they think they are going tor get a lot of money bak if they go to these preparer, which they really are. all they do get back what the internal revenue service has said. if you have a problem with your taxes, go to the irs. they're not the bad people to deal with.

if you have back taxes, they have your record where you can go in and get your record for like 207 and 208. and they have it all, even if you don't have your w2s. they have all of that information. >> host: charles, do you you generally do your own taxes or do you pay somebody to do them for you? >> caller: i actually did my own taxes, i did the long form taxes. but it's one thing about what they really want you to do. they want you to use a person who's qualified, a cpa. and generally speaking right here in richmond, you can -- if you just have a job and a house and a couple inch of stuff, somebody would do your taxes for $100, $150 and i've seen people go to a tax preparer and they have terrible tax and they sit down right in front of you and

use a computer and then charge you $150 while you watch them. i've seen people do that. i'll tell you something else, too. i'm a black individual. you'll find out that a lot of these individuals that come up with these islands, different islands, whatever, they're good at that. they are good at taking your money and charging you a lot of money. and they look at the average black person in the united states like they're stupid. >> host: and we'll leave this there. we got this twitter message from joe, the american hero who writes maybe they should have timothy geithner test people to make sure they know how to pay taxes. more from the article on the "washington post." the new testing and education standards will exempt certified public accountants, lawyers, and tax practitioners known as enrolled agents who are cleared to represent taxpayers in

dealing with the irs and are already subject to professional or government requirements. the irs said that it will take a closer look at the performance of those groups and that it has not ruled out testing them in the future. toledo, ohio, andy on our line for independents. what's on your mind this morning, andy? . >> caller: well, i'm definitely against the irs getting any more regulatory powers. it's pretty obvious the guy that you just had the twitter on there -- the guy that's running the irs can't do his taxes, how can they help us do our taxes better. they are incompetent at everything they do. they need to abolish the irs if anything. that's all i got to say. >> host: thanks for your call. no more regulation should be placed on the irs to stop levying punitive taxes and fees. back to the phones, atlanta, howard, on your line for democrats. go ahead. >> caller: yes.

i believe that they should really be regulated and i don't know why that's taking them this long to come out with this. but i think the main problem sounds like there has to be some kind of standards federally and state level -- there has to be just a standard even for efiling there is really no, like, requirements for whoever is filing your taxes. >> host: howard, do you do your own circulars or do you pay somebody to do them for you. >> caller: actually, i'm a person who can read and write but i really never thought about trying to fill it out myself. i just don't want to make no mistakes so i go to somebody and pay them $150. >> host: do you feel like you would have more confidence in the person who's doing your taxes if you know they passed some sort of government test or had to be licensed by the government. >> caller: well, i probably might be in a better position to

judge if that person is a good preparer or not. but there has to really be some standards. i mean, it's so funny that like i always thought i got three kids and probably i get some refund. i thought it's big. but sometimes i hear somebody just got one child, a friend of mine, who gets like double of that. i mean, it just sounds so funny. how can somebody get that big and somebody also, you know, probably in the same range -- >> host: maybe you should have that guy doing your taxes. thanks for your call. a little bit more from the article in the "washington post." irs to regulate paid

>> host: back to the phones. okeechobee, florida, m.b. on our line for republicans. go ahead. >> caller: yes, sir, i had a problem with the irs many years ago that leaves me with a bad taste in my mouth. my mother -- my wife did my taxes for me because she was a bookkeeper and she was coming down with alzheimer's and for some reason she didn't pay our taxes -- >> we'll leave this recorded portion of "washington journal" and take you live now to the white house and today's press briefing with press secretary rob gibbs. >> everyone who did not have a seat stood.

before we get started with a few questions here let me make one quick scheduling announcement. the president will travel to ohio on february january 22nd the next stop on the white house to main street tour. president obama will meet with ohio workers, local ceos, small business owners and other local leaders about ideas for continuing to grow the economy and put americans back to work. >> we didn't understand the county. >> lorraine county in ohio, january 22nd, 2010. >> happy new year to you. will the president be unveiling any new steps for policies today or would you characterize this as a recapping of what the government has done since the incident? >> well, let me -- let me break up the meeting, which is scheduled for about 2:30 in the situation room. i think you guys have the

participants. the meeting is scheduled now to go almost an hour and a half. the conclusion of the meeting, the president will make a public statement. i think not getting ahead of what he'll say, i think you'll hear the president give an candid update on where we are in the review. outline the specific steps that have been taken to strengthen security in our country and particular airports over the past several days. and go through some time lines about additional security announcements that may be forthcoming. say again? >> questions? >> no, he's just making a statement. >> so additional steps may be forthcoming but in the necessarily steps to be announced today? >> right. >> will he be challenging the agency heads about, in their purview, what went wrong in seeking some accountability there? >> as you know, the president

requested this review right after the incident that took place on christmas day. many of those reports -- the reports have come in -- some of one of the agency's came in a little bit late because of an incident that happened that you all are aware of. the president has had an opportunity to review those initial reports with mr. brennan in the oval office for about an hour yesterday. along with other members of his national security team here in the white house. i think you heard the president's statement over the break. and the president has a series of questions that he's asked all of us to look into. and he'll start going through those questions and looking for answers that are satisfactory to him and to the american people. >> is there any talk within the

white house where you can speak about this about any military response against suspected terrorist training facilities in yemen, for example? >> i don't want to get into information like that. obviously, you should pose that question to the pentagon. i think suffice it to say, and you've seen it over the past several weeks, we are strongly supportive of the efforts by the yemeni government to take strong action and to root out terrorists that are members of al-qaeda in the arabian peninsula. we'll continue -- we'll continue to do so. and continue to be supportive of those efforts. yes, sir. >> the president has come back with the holiday with quite a bit on his plate. >> he left with quite a bit on his plate. >> it's still there on his return. now counterterrorism has shot up the list and taken greater prominence because of the bomb plot. the question is is there any concern within the administration that this may

distract him from his domestic priorities such as jobs, economic recovery and healthcare? >> the president understands and believes wholeheartedly that keeping the american people safe and secure is his first job. nobody here would ever describe that as any sort of distraction. secondly, i think if you look at -- and you'll hear the president discuss this today, the actions that we have -- that we have supported in afghanistan, in pakistan, in somalia as i just mentioned to ben in yemen are not things that have happened since the 25th of december. those things were happening -- have been happening for quite some time. so the notion that somehow this got put on the president's plate in the intervening 10 days i think is something -- given the amount of time that he spent

working on these issues -- i don't think i would agree that somehow this is -- this is something that's been put on his plate over the last few days. these are, obviously, threats. and places in the world that are supportive of terrorists and terrorist organizations have been something the president has been dealing with since the transition, before he was even sworn in. >> but arguably the president would have been come back from the holidays to deal with things like job creation, economic recovery, he spent his first day back yesterday and a large chunk of the day in meetings, very intensive meetings about -- >> i guess my point would be met that i don't think -- we didn't have a mindset that this problem didn't exist prior to december 25th. the president spends, as you know, each day getting a daily intelligence update.

>> nobody is saying that they are saying you blew it. >> helen, let me just answer matt's question and then we'll get to your question. >> the president has spent part of every day since he's been here working on terrorism, working on terrorist threats, working on -- dealing with extremists. we've talked about afghanistan. we've talked about pakistan. we've talked about many of these issues. you know, i wouldn't quickly with the fact that the president has a full plate. i don't -- i don't think that you would find that the president wouldn't find his plate all together a lot fuller than it was quite honestly just i rqrj used to carrying around otherwise full plate. >> some of the measures, the reforms that the president and the administration are talking about including tighter

security, more stringent safeguards on visas, people being added to the selecting of no-fly lists having to do with challenging assumptions. can you look at the path from yemen to ghana to nige dpeegear nigeria and amsterdam to detroit. >> i think the president will begin to get into that some today. and in the coming days as a the review continues and wraps up. i think what you'll hear again from the president -- part of what you'll hear from the president today was -- is to go into a number of steps that we have taken but also to walk

people through the systemic failure that the president pointed out had happened in his remarks last week. >> he also in his remarks mentioned human failure. and so far, as far as i know, nobody has lost their job or been reprimanded. not to pick on admiral blair, but it is the job of the director of national intelligence specifically that job was created to connect the dots. is anybody -- is anybody at all going to lose their job on this. >> the review is going on. the president will begin to discuss aspects of that review today. i think the president is anxious to sit down. he's obviously spoken with a number of these individuals over the course the many days and he's anxious to sit down with them as a group and review this. i think the president has discussed in ensuring that adequate steps are taken to ensure the american people's safety and that's what he'll be

discussing and working through today. >> one final question, if i may. how cooperative has the terrorist been after he was arrested and since he got a lawyer? >> the subject, as you know, was taken from the plane in detroit. fbi interrogators spent quite some time with him. i don't want to get into all the specifics, but i think they would agree and i would say that he has provided in those interrogations useful intelligence. >> and since he got a lawyer, anything? >> i'm not going to get into all of what he said. but again the interrogators say he provided them good intelligence.

>> what are some of the concerns about some of the same questions were asked now were asked after 9/11. all these years later obviously there's been some breakdown, a communication breakdown, information-sharing within the intelligence community. >> i think the president will get into some of that today. i think the american people will hear directly from their president today on some of those failures. i don't want to get too far ahead the review itself. i think there are some substantive differences from what we saw in the pre-9/11 days that have and were addressed between that incident over the past eight years. >> but there is a skepticism there. >> while there are some -- while this involves intelligence, i think some of the problems are

not completely analogous too. you'll hear the president talk about that. i think you heard john talk about that over the weekend. and i think -- the president's charge in these reviews, both in the watts listing and in the detection capabilities review that's been done by the department of homeland security -- look, the president is as frustrated as i'm sure many american people are. we've spent a lot of money in the intervening years. we have set up new positions. we've stood up new agencies so to speak. we have to ensure and i think the president will strive to do so to reassure the american people that all that can be done is and will be done in order to protect them. >> the question on healthcare, c-span television is requesting leaders of congress to open up

the debate to their cameras. and i know this is something the president talked about on the campaign trail. is this something he supports and will be pushing for? >> i've not seen that letter. i know the president is going to beginning some discussions later today on healthcare in order to try to iron out the differences that remain between the house and the senate bill and try to get something hopefully to his desk quite quickly. helen? >> a couple of questions. before pearl harbor, the navy didn't talk to the army and war department didn't talk -- was there a lack of coordination on all the security information we've had? and what is the core reason you think or your the president thinks for terrorism? >> he's your president, too, helen. >> what do i think? >> you asked me about my president. >> i thought it was our president. >> well, i agree. you added a why to our and somehow and came up with your. [laughter] >> go ahead.

i interrupted -- >> is there any coordination? is there a coordination balancing on intelligence? >> building on what i just talked about with dan. i think the president said quite clearly there was a systemic intelligence failure. >> a breakdown. >> the president will discuss that more today. and what the review has preliminarily shown. and will begin to go through some of the things that we have done as well as the team will begin to work through all the additional steps that the team and the president believe must be taken to ensure the safety and security of the american people. as i said to dana, you know --

when we get through the review, i don't think it's completely analogous to some of the walls that the bureaucracy had constructed prior to 9/11. i think some of that obviously has been knocked down and there is -- there is -- there's a greater amount of information-sharing. and there's a greater amount of sheer intelligence that's collected. the president wants to know where the systemic failure happened and what we're going to do to ensure that we can do everything in our power to make sure it doesn't happen again. i think you'll hear the president talk about that. >> is that possible? and also what is the core reason why they want to blow us up? >> i don't know that i'm the best person to speak for some of their actions. >> having information you said.

>> well, look, again, i think for whatever -- for whatever awful and murderous reason that people seek to get on planes and do innocent people throughout the world harm, i can't speak to the type of deranged mentality for somebody to do that. >> you don't know who's motivating all of this? >> well, i can certainly name is few of them. i think the president, though -- his job is to in this instance do all that we can to ensure that every step is taken to prevent it from happening. >> that's not answering my question. >> maybe i misunderstood you. >> what is the core reason had the administration decided why -- >> well, i think there are a number of reasons. and i think they have stated in various messages and videos, all

sorts of reasoning for why they seek to do what they do. i don't think any of it in any way would ever rationalize the actions of what we saw on christmas day. >> i'd like to return to our original question. there are some people who believe that the only reason this was not a catastrophic disaster was luck. that abdul screwed up in making this device work. and as helen said a lot of people the president and his administration simply blew it. would he agree with that? >> i don't think i'm going on a limb the president said there was a systemic intelligence failure. yes. >> the average person would say they just blew it. is that going too far? >> i don't know what the substantive difference between the two are. >> okay. so it's the same thing, basically. >> i think the president quite clearly said that a failure of

our intelligence service happened in allowing what we saw on christmas day to potentially transpire, absolutely. i think the president said that about a week ago. >> does the president take any permanent blame for that. did he believe he did not pay enough attention to these issues? >> no. i don't think that's the case, no. >> so the fact that he had this incredibly full plate did not, as we say, distract him from spending the time needed? >> we spent an awful lot of time talking about -- you've asked me a lot of questions most of which i can't answer on camera. about different activities, the president -- nothing has distracted the president from keeping us safe. >> in hawaii, a lot of people -- well, while he was in hawaii, a lot of people back here, critics, accused his initial

response initial and weak and he should have come home from hawaii and dealt with this thing on a full-time basis. what does he feel about that? >> you were in hawaii. >> i was. >> i recall you guys being somewhat busy. the president -- the president worked on this throughout his time in hawaii. he worked on it before he left. and he's worked on it since he's -- since -- >> the idea his initial response waiting three days was slow and his statement was as a matter of fact -- >> it keeps pundits employed. >> on full body scan, how important is privacy in all of this? do you think -- does the president believe the american people just have to get used to the fact that they're going to have to undergo these embarrassing procedures? >> i think the administration beliefs and i would point you specifically to dhs on this that we can easily achieve a balance that allows us not to give up

our privacy but at the same time protects us from those who seek to do us harm. >> a few follow-ups just on everything. first on the follow-up to ben's question on ruling out -- ruling in or out military -- u.s. military intervention in yemen. is it fair to say that the president's position during the campaign, for instance, on pakistan, which was they don't act, we will. that's his position when it comes to all things al-qaeda? and so that could be regardless of country, regardless of border? >> i don't want to draw -- i don't want to -- i don't want to parse your question but at the same time suffice it to say, this government and this administration makes use of actionable intelligence. how about that? >> and so -- when it comes to al-qaeda and pakistan, there's no reason to think that yemen -- i know you don't -- there's no reason to think -- >> chuck, you know, i think i answered ben's question.

you understand that i'm not going to get into what we do with actionable intelligence. >> fair enough. follow up on jake's question, it's been reported that he is not -- he's clammed up over the last few days. does the president believe if he were an enemy combatant that they would still be able to get intelligence out of him? >> the terrorist spent a number of hours with fbi investigators in which we gleaned useable, actionable intelligence. the decision to -- the decision was made in this case similar to previous decisions that have been made with richard reid, with zachariah moussaoui, with jose padilla, fbi investigators believe they got useful information from this terrorist.

i don't see despite what you hear otherwise, i don't see -- i honestly don't see the point that is being made when you look at past decisions that were made by other administrations. >> you said that the fbi got actionable intelligence. >> and you know i'm not going to -- >> well, can you at least say -- without saying what it is, can you say so have there been plans implemented since you have this intelligence? >> i think it would be a bad precedence for me to begin to discuss that intelligence from here. >>w3bb and finally, on the meet today, is the president going to be issuing to the intelligence folks in particular -- i mean, i understand this is sort of two parts of the security -- homeland security aspect and the intelligence gathering aspect. is he going to, after receiving these reviews, at least to all

of them -- but how is he going to make sure the review process continues, i guess? i mean, is he setting benchmarks saying, look -- >> i don't think the review will be in today. i think we'll have more on this in the next few days. let me -- one part of your question. i don't think the president -- i think what we have to do is make sure that we're not in the mindset of looking at homeland security and intelligence as two different silos. i think what dan and what helen have said and what this review the president has asked us to concentrate on is to ensure that information can move across.r+6 the problems that were gotten into pre-9/11, 2001 were in silos and couldn't get across. >> it does seem that you believe -- that the systemic failure and human failures happened more on the intelligence side, more so than on the security side of things;

is that fair? >> yes, yes. though i will say this. again, one of the things -- again, you know the president has two reviews. one of those reviews is a detections capability review based on substances and this individual getting on this plane with what he had. >> a couple of things. first, the british government yesterday and today said that they had passed on the information about abdullah and his times to britain to u.s. intelligence. do you have any comment on that and do you have any -- any description of the nature of that? >> like i said, chuck,g+j> okay. and second, we know from these agencies already that a lot of these reports were them saying they weren't to blame, somebody else was to blame. >> i'm sorry.

this is based on -- >> based on people fromsuñ thos agencies saying well, our report basically says -- and secretary clinton yesterday -- >> let me say this, let me short circuit your question.nx#hex a week ago the president said we had a systemic failure. when the president did that, the president -- we're going to move beyond agency finger-pointing. we're going to break down whatever silos exist from information being collected and shared. that came from the president. i don't think anybody should misunderstand how that should flow to each and every agency. this is a far more serious game than trying to figure out which agency can blame which other agency. that's not the point. the point? to ensure that what we collect is processed. that as it's gathered, it's processed and that it's used to prevent something like this from happening.

the president will ensure and i can assure you today that the president will discuss this in the situation room. the president will not find acceptable a response where everybody gets in a circle and points at somebody else. the american people won't%vp3 that. >> can you give us a little bit on what the president intends to talk about with democratic leaders this afternoon? is this action negotiation or are they trying to set up a process for considering the -- >> let me -- we'll have a few sentences afterwards. obviously, they will talk about -- look, i think in terms of talking about healthcare, they'll talk about the great, vast majority of the twoî bill that coincide and we will, i think, begin to talk through how we work out what limited number of differences there are.

>> okay. there's been some talk of not ç a normal conference committee on capitol hill just through this informally probably behind closed doors. does the president have a view whether this should be an actual conference committee or just be negotiated -- >> i think the president is anxious to get the differences worked out and get a bill to both houses and passed out of them.gr i think you can go back and look through the past many years and see where situations -- where they work out the differences it happens very similarly to what the president has engaged in now. >> just lastly, why can't you answer the c-span question? >> i did. >> why do you need to see a letter. this is something -- >> dan asked me about the letter and i haven't read the letter. >> i'll just ask you about having it on c-span -- >> i answered dan's question and i answered this before we left

for the break. keith, the president -- the number one priority is getting the differences worked out. getting a bill to the house and the senate. we filled your newspaper and many others with the back and forth and the details of what's in these bills. i don't -- i don't want to -- i don't want to keep that from continuing to happen. i don't think there's anybody that would say that we haven't had a thorough, robust, now spanning two calendar years debate on healthcare. >> there are a lot of reasons not to do it on c-span. people could show -- >> no. >> are you talking about the agency finger-pointing but does the president feel like, yet, that i can conclude which agencies dropped the ball more than others and do we expect to hear that later today? >> i think the president will be candid about what we found. and i think -- i think in the

coming days, we'll have more on what happened and why. >> and does he still -- getting back to jake's question. does he still have full confidence in blair and panetta? >> he does. and those agencies will continue to take part in this review process and will continue to find out what happened. >> and one last question, friday is the next jobs report. not going to ask you to guess what's going to happen. >> yeah. the last time i did, the market went haywire. >> but -- [inaudible] >> just write down what i say, not what you thought i said. >> over the past few months, around the jobs summit, the allentown supplement, is there anything planned? >> the president will make comments about the report. i have not looked through the blocked schedule. there's no travel that's planned for that day.

like i said, he will -- he will do a statement and respond to the jobs report. yes, sir. >> the president said he would hold people accountable. can you define what that will be and how the american people will know it's happened? >> i think i discussed this earlier. this is -- accountability is part of the ongoing review. you'll hear the president talk about where we are in that review process. as that review continues. >> does accountability necessarily mean someone needs to lose a job? >> i don't want to get ahead of the end of the review. >> so it's possible that accountability would not include someone losing -- that doesn't have to be a necessary measure of it, is that correct? >> i'm going to wait for the review to take -- to finish and announcements to come after that. >> okay. the president also said that there were pieces of information that had they been put together would have prevented the suspect from getting on the plane.

john brennan said sunday a couple of times there was no smoking gun. can you help the american people understand those two statements? ..

>> i think that -- i don't think the american people -- i do not believe the american people have lacked for information on what's in these bills, the political and policy arguments around different people's position. i think that's been well documented. >> okay. let me put it this way.

what's going to be determined in these negotiations is the final product, not what one body of the legislature believes is necessary. and the other disagrees with, but what the final application will be. >> that final implication of that product will then go to the house, where they will debate and discuss and ultimately vote on. then that final implication of the product will go to the senate where 100 equally sworn members will debate and discuss that topic, and then hopefully it will come to the white house in an intervening time period where i assume that product will be debated and discussed before the president signed into law. >> but before reaching the house and senate floor -- >> i think you can get a sense of where -- you have at least the part property lines of where we are talking about, because once that is in the house bill, one set is in the senate bill, and it's a different policy proposals that we've been talking about since it was a lot warmer out than it is not.

>> last question. >> i think we started back when it was called then it got warm and now it's called. >> back to flight 253. you said this was an intelligence to to a deceased younger. did the state department fail anyway? yesterday secretary clinton said we met all the interagency requirements. is the president satisfied with the response like that? >> let me do this. i don't want to single out -- you will hear the president speak about this review later. i think when the president talks about systemic failure, he does not absolve any agency in this process, as a review, looks through what happened. i think, again, if -- >> if we followed all unnecessary procedure and it still happened? >> listen, if everybody had done everything you could, i've heard the president, that we wouldn't be discussing flight 253 on

christmas day. unless or until we can be convinced that we are doing everything in our power, to ensure that we are taking those steps, the president will not stop asking questions. >> if i could follow-up on that. isn't one of the problems the fact that some people were abiding by protocols, and those protocols are inadequate? >> there's no question. we talked about this in the initial days afterwards. we have, one of the reasons why the president has asked for john specifically to go through this watch listing, there are -- there's a tight database. there is a terrorist screening database from which, tides is a larger pool that is drawn into this terrorism screening database from the terrorism database, a subset of that makes up the selectee, and ultimately

the no fly list. would have to enter the protocols that have been in place and developed sense for many, many years, don't prevent either information gathering or information sharing so that somebody that's on a tides list can go to the screening, the database screenless and ultimately to fly. you will hear the president talk about all this information that is gathered and collected, been fully analyzed, i think the president, you heard him say and i will reiterate, that what somebody -- what started in a tides database which is sort of a global record system of individuals of concern, doesn't get berthed up into something like the selectee of the no fly list. there is no doubt we have to examine the existing protocols as the tactics and techniques of

terrorist change, to ensure that we are staying ahead of what they are playing. >> is out to make it real-time procedure? letzig are not on the no fly list but there's something about your presentation at the airport, cash, one way, no luggage, that pushes you up -- >> i don't want to get ahead. i think what -- right, what john brittain will do is look through the different protocols, the different ways that information is gathered and how we move people from tides to screening, ultimately disliking the no fly. some of the reasons i think you heard john say, cash, cash is used in africa to buy a plane ticket may not altogether, isn't necessarily going to be something were summary says wait a minute, that individual.

now, that plays a series of other things, all analyzed together, right, could and should take somebody from a larger pool into a selectee or no fly. there's no doubt about that. >> can you describe that he attempted bomber affected guantanamo bay facility? >> first and foremost, we have undergone a rigorous process to analyze all that were at guantanamo bay. some have been transferred to their home countries. some to other countries. either because the task force determined that it was okay to do so, or in some cases, judges have ruled in habeas cases that the government no longer has an acceptable reason for keeping that individual.

again, the task force will look through those. we have obviously worked through legislation to reform military commissions. we've indicted individuals in article iii courts and some of those trials will begin soon. so, and i think you heard john say this over the weekend, that one of the very first things that al qaeda in the arabian peninsula use as a recruiting tool was the existence of guantanamo bay. john has stated clearly that we are not going to make decisions about transfers that, to a country like yemen, that would -- that they are not capable of handling. and i think that, while we remain committed to closing the facility, the determination has been made right now, any

additional transfers to yemen is not a good idea. >> can i just follow-up on that? that potentially moves up the number of people that might be sent. can estimate? >> i can't quantify, again, you know what i just said to michael. obviously, we would not move additional people into human right now. >> robber, you said at the protocols were inadequate and these things were being reviewed, should americans be fearful of flying either domestically or internationally? >> i do not believe so. because -- well, i believe that the system that we have right now, the enhanced security procedures that have been implemented, provide a measure of safety and security for

travelers, either going domestically or traveling to and from this country overseas. you will hear the president discuss today what has been done through dhs and tsa for additional screening activities, and indifferent security protocols to ensure that safety. >> on a separate matter, on the fort hood review, does the president plan to make a statement on his assessment of the review that was presented to him in hawaii? and will that review ever become public? >> i will check on that. i know the president received from john, the 23rd prior to leaving, a preliminary investigation into that. i know they discussed some of that. while he was there and had discussed that since coming back. and i know at some point we will

finish that review and make it public. >> at some point will he make a statement on that though, on his assessment? >> i assume so. first and foremost, we're focused on the meeting and the assessment today. >> a couple of questions on the third uninvited state dinner guest. what was the presence reaction that there was yet another? >> i'm not going to get into this. yesterday, we directed and we will do so today, based on a criminal investigation, we direct you to the secret service. >> how does that affect -- >> because i've talked to the lawyers and that's the recommendations that was given to me. is that both of your questions? >> well, there were a couple of others. that are not part of a criminal investigation. >> if it's that incident. >> thank you, robert. on north korea, does the

president make any list of north korea speaks at one wartime. >> does the president make any decision to release north korea as terrorist country. >> has the president made a decision? our posture on that has not changed. today marks one year exactly since the president nominated don johnson to be the office. does he plan to renominate her in any other, more broadly speaking how does he respond to criticism from liberal organizations that he hasn't put enough muscle behind getting his judicial and executive nominees confirmed? >> i don't know what decisions have been made about nominees that have, as a result of being, having passed the year, need to

be renominated. i can serve a check on that. i would say that we are proud of our record of hitting individuals into government, though disappointed at the pace in the senate and working through things both executive branch and judicial branches. >> thank you, robert. you said earlier that the president had full confidence in admiral blair and the director, correct or does he have the same confidence in secretary napolitano? >> he does. >> there has been no stunning out of people outside the administration to wait in the wings are a possible shakeup? >> no. >> the other thing i want to ask was, do the intelligence chiefs, who have been meeting with the president, do they feel the interrogators had enough time with abdul mugabe for the lord came and? >> my understanding is the fbi does believe so, yes. >> and the cia? >> i have not talked directly to

them. i can certainly look into that, but you know, again, if you look at decisions that were made about richard reid, richard reid, after i think less than three days had already been indicted. which puts him in the criminal justice system here. he was tried in boston and is now at a maximum-security facility in florence, colorado. the same is true for zachariah miceli. he entered the criminal, u.s. criminal justice system and convicted, not far from here and sent to colorado as well. >> was a president ever briefed about things like the tides list and how that works, or airport security? or did he ever ask or was he sure that all this work ever before loses? >> i don't know the full answer to the degree to which they had

gotten into the tides database or that. i conservancy. obviously the president spent a lot of time discussing potential threats. >> does the administration have in response, and are there any concerns about increased demonstrations like these happening against the president? >> i would point you to the secret service on that. i don't have anything on that. >> thirteen state attorneys general sent a letter to congressional leaders saying that if nebraska clause isn't in the final health care bill, that they would bring legal action. based on equal protection clause and arbitrary spending. does the president believes the nebraska clause is constitutional? >> i have not talked to the president specifically about the letter from the attorneys general. i do not believe that anybody

has legitimate constitutional concerns. about the legislation. [inaudible] >> talking about the senate bill, so i don't know what that lead you to. >> since the christmas day incident involving flight 253 there's been increased scrutiny upon people flying into this country from 14 mostly muslim countries. i'm curious, i've heard this from many peoples, why did it take eight months, post 9/11 to get to this point, as far as increased for those individuals flying into those countries. and -- >> well, dhs and tsa have put in to place for the foreseeable future enhanced security. they are not chosen by -- they are chosen by what has been

determined as state sponsors of terrorism. that's how that list currently has been, and in other ways, has been devised in the past. >> like post-9/11, just to get to this point we are right now? >> i will doublecheck on that. >> did the president played any role in john kerry's decision not to run for governor of michigan and as a the white house playing any role now in talking to democratic candidates about running? >> none that i'm aware of in the decision by the lieutenant governor today. and i can check with political affairs about something ongoing. >> robert, chairman charlie rangel of ways and means suggest that the conference will be just

the sight of a rubberstamp. is there anything in specific that the president would like to see be include at this point and a final conference bill? has the president accepted at this point this will just be pretty much a quick run through? >> look, we've discussed in here over the course of many months what will ultimately be or what is ultimately part of the few differences in each one of those bills. that's what the president will, and leaders on both the house and senate side, will go through. again, we hope this is a process that, because of the sheer nature of how much in these bills, and these bills that these bills have in common, that this is a process that we can conclude and ultimately get a bill quickly to the president's desk. thanks, guys.

[inaudible conversations] [inaudible conversations] [inaudible conversations] >> president obama will be making a statement at 4 p.m. eastern time today following his white house meeting on the attempted jetliner attack on christmas day. you can watch the president live on our companion network, c-span, later this afternoon, 4 p.m. eastern. we speak to a capitol hill reporter about today's white house meetings on airline security and health care. >> we're joined by wall street journal white house reporter jonathan weisman. president obama gets back to work.

who's going to be at the meeting at what will the president your? >> you don't have time for me to list everybody who's going to be the. is going to be secretary of state hillary clinton, defense secretary robert gates, janet napolitano, the homeland security department, attorney general eric holder, steven chu from the secretary of energy, dennis miller the director of national intelligence, leon panetta, robert miller from the fbi. and national counterterrorism center is going to be there. basically, anybody who might have anything to do with terrorism. i mean, as i said, steven chu, the secretary of energy will be at this meet. >> and the bottom line is what is he going to hear from all these folks because they are supposed to go agency by agency over reviews that each one of them was supposed to conduct on how it was that mr. abdul, farouk abdulmutallab, the young

nigerian man who tried to blow up that northwest airline on the way to detroit, how that guy got onto that plane and what they're going to do from here. the president will be speaking before, and we are asked beckoned him to make some announcements. there's been a drum roll up to this meeting that we do expect something of substance to come out of expect any inkling on what that substance baby and those comments this afternoon? >> you know, the tsa, transportation safety administration, has been unveiling a lot of different new methods of screening. so we think it will be broader than that. the odds are that it's going to be something about, you know, bolstering the central dni, director of national intelligence. >> how likely is it that out of this meeting, or as a result of this incident, personnel changes will happen, or a resignation will be part of the fallen? >> you know, we have got no indication from the white house

that heads are going to roll out of this thing. obvious, there are certain people on the hot seat. dennis miller, the director of national intelligence, it was his job, really, the dni's job to connect the dots, to get the information coming in from the fbi and the cia and the national secret administration agency to put these things together. and that was kind of where the failure has come. the president has said that. but we have gotten no indication that dennis blair job is on the line here. nor have we gotten any indication that homeland security secretary janet napolitano is under threat, even though she came under a lot of criticism when the day after the bombing incident happened, she said everything had worked fine. so i'm not looking for jobs to be, you know, to be lost here. but i think the president will have some stern words. i've been doing that before big and i do think that he's probably going to have some

policy announcements to try to bolster this idea of connecting the dots. now, unfortunately, we heard a lot about that after 9/11, and we're still hearing about it. >> the president also today will be meeting with capitol hill leaders that they are meeting earlier on the hill to talk about health care legislation. then meeting with the president this evening. what's the purpose of that big? >> well, that is really to get the ball rolling on the conference meeting, the meeting between the house and senate, to try to get the final deal on health care. the emphasis this week really is going to be on the house. especially if the house liberals will go along with the version of the senate, other health care bill that came out of the senate. the fear here is really that they are going to lose the senate, just one senator, not that nancy pelosi isn't going to be able to round up her people,

but the president wants to hear, all of the factions of democrats in the house and make sure that he can keep them online and get this done fast. >> there are news reports today that democratic leaders plan to go it alone without republican in the. would the white house support that? >> absolutely. look, they have been doing that pretty much the whole time. the white house made a concerted push to win at least one republican in the senate. the president personally focused on the link is to, the senator from maine. in the end, all of those efforts, more than a dozen phone calls, meetings at the white house, they came up for not. not. olympia snowe said she couldn't support the bill unless negotiations led into 2010. they weren't willing to do that and i think the president will say, we gave the republicans all the chances that we need to. now we just need to get this thing can. >> keeping his eye on the white house today, jonathan weisman. thanks for the update.

>> thank you. >> again, the president will make a statement on airline security following his white house meeting today. that's coming up at 4 p.m. eastern time. is live on c-span.

>> by and large, the people that cover us like their work. as you indicate, they know our traditions that they know the schedule, and they do a very good job of reporting. this observation. the news cycle, the interest, the attention span being what it is, they have 24, 48 hours to make the point. well, we write for a different time dimension than that. it's not just come it's what the principle is. the press does a very good job of reporting what we do. it's a little more difficult for reasons i've explained, to report why we did it. i can understand that because they have a 24 hour, 48 hour news cycle. so they have a tough job. they have a tough job. >> this is the supreme court pressroom. on the day when several opinions

have been released from the bench. in this program, we hear from two journalists who regularly write about the institution. >> lyle denniston has covered the courts for over 50 years. and joan biskupic has written about the highest court since 1989. >> i think it goes a certain kind of reporter. we're all in it of course for the chase and for information, but we tend as a group to be a little more of a bookish crowd. we all carry yellow highlighters with this. we love to read opinions and look back at president. i think all of us appreciate the law, and joy. and i think it draws a different kind of reporter that way. it's on a school year cycle. it draws a lot of us have gone to graduate school, law school. we somehow don't want to break out of the school year cycle i think. >> the supreme court is the most mysterious branch to the public. they are not recognizable

generally to the average person on the street. and then they speak to the public through their opinions. so in some ways, they are very public, because anything they do that will matter in your life, will be down on black and white, in a court opinion. but yet, they themselves will not be publicly announcing that before a camera. so there is a real ministry to the supreme court. also, face it, it's the law and the law can be complicated to many people. answer that gives them an element of exactly what are they doing up there? and everything is based on precedent. so their current goings are based on rulings from years, decades, even centuries ago. so i think, i think that gives more mysterious aura than the two other branches of government. . .

>> ins some justices that still write out their opinions longhand on a legal pad rather than the computer like most people would do today. the whole thing is set by tradition. oral arguments go for a specific hour. a white light goes on when there's only five minutes more left in the argument. then the red light. there are certain days that they have their meetings. the court runs in its own rhythms and orbit. chief justice rehnquist didn't like to have any of those disturbed. newer chief justice roberts is a little bit more flexible on things. but i have to say his predecessor would often interpret someone speaking right when the red light went on. even in mid syllable. >> this is the chamber from

brown versus -- the most important decision in defining presidential power was decided in that room by human beings sitting on that bench after having listened to argument by other human beings. and the aura of the place is present. it doesn't make -- there are some bad lawyers who appear before the supreme court who just aren't up to the task. there's something about the feel of the place that tells you that something really important is going on here. to my mind, it's very much difficult from watching a debate on the floor of the house and senate. where you realize what may be going on on the floor any given moment really doesn't have anything to do with the legislative process. it's something making a speech

about how important mother's day is or how we should honor a certain kind of animal husbandry or something. everything that goes on in the supreme court is related to something important. it's a part of the process that's working from beginning to end. and it'll result in an outcome. it's all meaningful. >> i really like a lot of the elements of covering the court. i love oral arguments. i love to see them up there and how they respond to each other as well as the advocate that stands at the podium before them. it's not televised. people don't know what's going to go on. the whole room is beautiful. it's this deep crimson, velvet, and white marble, and two american flags, and the justices

come in in their robes. they have a very active bench. there's a lot of give and take. and that's very intriguing to watch. sometimes you can get clues, sometimes they surprise you when they finally issue an opinion. it's not where they appeared to be headed when they were on the bench. >> i don't think television cameras in the courtroom would make any difference whatever. there is an ongoing debate, and there has been for i suppose it's probably never going to end as to whether the presence of cameras in a court changes people. you know i suppose that debate was a responsible debate along time ago.

even in the federal courts now where they are experimenting now and then with big cases, they will allow the cameras in. i think that judges are sufficiently aware of the craft of judging. having an observer of the process is is not going to be different. in terms of how it affects the process. whether or not the observer has a notebook pad as i do or a camera taking images of what the court does. that's debatable. i don't concede that. i think judges who are aware of what they are supposed to be doing will not play to the cameras. i don't think the lawyers will

play. a lawyer knows that they have one task. that is to persuade five people. that's all it takes to win is five of the nine. and if you get up there at the podium and you're playing to the cameras because of the audience out there, the chances are fairly good that you will lose the focus on the five that you're trying to persuade up in front of you. if you are sitting on the bench, if you are one of the nine sitting on the bench and you are thinking about what the audience out there, looking at the camera image is thinking, you're going to lose a focus on what's happening in front of you. the dynamic of an oral argument is such that you got to participate in it to really make it work for you. because the justices use oral argument very often to try to persuade each other. and oral argument when

propertierly understood is an agenda setting function. what is discussed in that one hour of time is going to be very heavily influence the conversation that the justices are going to have when they retreat from the bench and go back in the private conversation. that conversation already has started while they were on the bench. i don't think so, your honor. >> 4%? >> no, your honor. >> well, actually -- >> 8 is 8%. does it stop being a quota between it's somewhere between 8 and 12, but it is a quota if it's 10? >> there is still a residual sense that somebody would react to it and have it up. justice scalia has said one of his reasons is he thinks somebody would play to the cameras. if among the nine justices who have been most recently sitting

in the court, if anybody would play to the cameras, i suspect the one most likely to do so is justice scalia, he's a bit of a necessary beian. >> -- thespian. >> justice scalia, for many years he was alone in his view. mostly speaking to people beyond the marble walls. now he has a majority on the court for his approach. meanwhile, he's such interesting figure. he's sort of larger than duck with his duck hunting with dick cheney, he's someone that i found that people want to know more about. he's very much out there. he's out there during oral arguments. he'll say very bold, blunt things when he's outspeaking to student groups. i thought it would be interesting to show how scalia became scalia.

they are very close friends, their friendship developed when they were both on a lower court. they are quite opposites on the law. she is quite liberal, she he was quite conservative. scalia is quite aggressive. she tends to pride herself in a certain tone. they are very close. they would go to the opera together. they celebrate new york eve dinner together. they have deep respect for each other. when they were lower court judges on the u.s. court of appeals for the d.c. circuit they would swap opinion and ask each other for advice on the language in the opinions. other justices have formed bridge clubs, they have traveled together. remember, they are appointed for life. so this is an a incentive for them to get along. there are nine individuals and all nine value colleague

quality. they are appointed for life. i think they were challenged after the george w. bush and al corp. that -- gore. that was their biggest challenges. they have their written opinions and sometimes statements from the bench given orally. but they all know that there's an incentive to try to keep getting along because they are going to have to share the building for many, many more years. many come and stay for 20, 30 years. i think that there's an incentive to appreciate each other's company no matter how much they differ on the law. actually, in recent years, most of the justices who have been appointed have been easy going enough that a tone was set that encouraged colleague quality.

>> however much you resent the wayer colleagues have decided, there's going to be another tough case coming up right after it. if the underlying is one of the working together, then you're able to have a real tussle over a case. once it's decided, move on. virtually everybody knows everybody else. and among the justices, and really, this really depends kind of on the patterns that the chief justice sets. as the chief justice wants a really together court, the chief justice can do things that bring that about. chief justice warren had a largely together court. of course, he always had to deal with the few that never seems to end with the feud between black

and frankfurt. earl was warm and friendly place and ran a court that was arguable with each other. the court under orrin berger was not a happy place. the relationships between the justices tended pretty rapidly deteriorate. there was a lot of internal resentment among the justices about each other. and the chief justice didn't work very hard at trying to dispel that. in fact, the way he ran the court at times contributed to that side of internal dips section. because he would kind of play favorites in the way he assigned opinions. he would sometimes cast his vote one way in order to have control over the assignment and then change his vote later on. he ran the court in a way that

has contributed to the internal divisions. chief justice rehnquist on the other hand ran a very happy court. remember that i'm talking about a court during the rehnquist years that was very deeply divided among philosophical and ideological lines. at same time, using that position which is, you know, nowhere is it defined that he should be the principal caretaker of the emotional state of the court. but he has that capacity, using the functions of the offense. and his leadership of the court. to make the court a harmonious place. or do the opposite. chief justice roberts is trying to hard to follow chief justice

rehnquist. he has a bit of a disadvantage. because unlike rehnquist, he was not on the court to establish relationships before he became the chief justice. and i think that helped with rehnquist. to have been one of the nine, and then to be the leader of the nine. and justice roberts didn't have that opportunity. and also he's considerably younger than a lot of his colleagues. which makes it a little more challenging for him to establish the kind of leadership potential that i think he ultimately will have. people who have known john roberts for a long time say that he's no more conservative than they thought he would be. he is more conservative than i thought he would be. but he also seems to be more -- if i will agenda driven than i expected him to be.

the court under john roberts is an institution that's i think very bold about re-examining long standing precedents. it's interesting, because a lot of the popular perception of him, particularly in the media, is that he's a justice, a chief justice who wants the court to move in more incremental ways, to take smaller steps as you will. there's that dimension to it. i think the chief justice in some ways generally does want to have app kind of minimalist. but there are times when -- when his conservative orientation, which is deep, deep inside him, i think. it leads him, i think, to want to push the court to try to take really bold steps. >> the most important power the chief justice has to assign

opinions. when the chief justices on the winning side, he would determine who would write that opinion for the court. that's a very important role. because that opinion will speak for at least five justices, a majority. but it will also guide lower courts and the public in terms of what the law of the land is. that's the most important role. but the chief justice also has a ceremonial position. he sets the tone. he's the one who runs the private conferences with the other justices. he's the member of other boards in town. it's both representative and substantive. but when it comes to the actual law of the land, his vote counts as much as the newest justice. >> judge sotomayor are you ready to take the vote? >> i am. >> i sonya do solemnly swear. >> i, sonya sotomayor, do

solemnly swear. >> and a new justice can change things, tip the balance, change the votes in a case. that's the most substantive thing that a new justice can do. it also changes the personal dynamic among the nine. imagine any kind of group, a group of nine, everyone sort of rearranged slightly to accommodate the personality, approach to the law, and how they do business. >> byron white used to say each new justice changes the whole court. i think what he meant by that was that because it's a court the of nine very, very particular kind of individuals there is a dynamic that develops in the group of nine. and the new justice can change that dynamic. it can come in with a kind of a different attitude, a different approach. i remember, as a matter of fact,

justice harry blackman said to me at one point, and he is really quite resentment about justice o'connor. that women came here with an agenda, and she needs to carry it out. he is unhappy with her, because, you know, his perception was that a new justice should come to the court and not be very visible for a couple of years until he knew the ropes. sandra came into the court and he was done throwing her weight around. he was very self-confident. i recall that before the end of november she came to work in october before the end of november. she was filing opinions dissenting from the courts decision to not wear cases. dissent is kind of bold thing to do. particularly if you are brand new on the court. so a new justice comes into the court. and brings a personality, brings a history, brings a style of

judging, a style of writing. because there is this constantly changing internal dynamic, the edition of a new ingredient in the dynamic changes the whole. now it doesn't cause other justices necessarily to change their views. but it does open up the possibility of a kind of shifting of majorities. a shifting little block within the court. >> a new justice who brings another female voice and who happens to be hispanic will bring great diversity into the bench. when the visitor walks in now, it's quite male and quite white. adding hispanic will certainly increase the diversity there and adding a second female voice certainly will do that too. when you think of how america is, you know, half male, half female, to have nine justices and only one be female certainly

appears quite lopsided from the reality of most visitors lives. but even two out of the nine won't be representative of america. but it will be more than there is now. when a new justice comes on to the court, a journalist wants to know how will they be as an individual. what will their personality, how will he/she decide the law? but then what will that individual do to the other eight? will she end up being someone who other justices play off of. will she play off of some of those existing justices? you know, new justice sotomayor happens to be from the bronx. we have a couple other new yorker out there who can give it pretty strong, lit toe is from trenton, and you wonder if there's going to be mixing it up. >> it is in this room, as they

begin the process, reaching the decision of the court. >> they go around after the order. after the chief justice has set up the case. this is what we're going to decide. here's the question. and then they start casting votes. starting with the chief justice. and then once every justice has been able to speech, they might have some give and take among the others. that's what they do for every case as it's been argued earlier in the week. also they go through on seniority. also if there's a discussion to be had for a case that might be up there on a petition or appeal. they have to decide whether to take the case and schedule it for oral argument. even though it's a very serious business. no secretaries or law clerks are allowed. it's just the nine justices.

before they start, they do a couple of things. they start with the coffee and pastries. they have a till that they keep, to foster some togetherness. and they all shake hands, all around. they do that before they go on the bench. justice o'connor said she loves the idea of shaking hands with a colleague. and sort of having that human contact before they were about to disagree vigorously. after they meet in conference, they all go back to their respective chambers and every conference is done in writing with a document that then is carried by messenger from chamber to chamber. if they want to change, or write a note to fellow justice, or changes subjected in language, the justice writes that down, types it up either through the computer or has a secretary type it up. then it is hand delivered to

another chamber. there will be occasion where the justice will pick up the phone and talk to another or justice will go into another chamber, but that is rare. they do things the old fashion way. >> that's a surprise that one discovers. if you pay close attention to the court. and if you look at the past papers of justices that are now often able in some kind of collection at the library of congress or at various universities around the country. the decisional process is very much a paper process, rather than one in which somebody walks down the hallway and tries to persuade each other. now there are exemptions to that. for example, when in 1992, the court was re-examining roe versus wade. three justices kind of put their heads together, justices kennedy, souter, and o'connor and fashioned a way in by which

the court could resolve to get it decided. and that was unusual to put together a tree yo that was -- trio that was managing and controlling the outcome of the case. they were able to get a majority to sign on to what they have chosen to do. then the draft starts circulating. what happens is the other justices will send what are called join memos. join me is a typical way you put it. which means you can count my vote for your opinion as it is. there may be a note that says i'm going to write separately. so i'm not going to join your opinion. or i will support your opinion

but i still have to write separately. or i'm going to dissent, or there's another approach that you can take. i will join your opinion, if you make this and this and this change in it. but that's usually done as a paper process. it's not something where the justices get together in the conference and say, what do you think about it? what do you think about it? it all comes in as a paper flow. and the person who has the assigned task of writing the opinion then decide whether or not to incorporate the changes. if it's a close case where you are at risk of losing your majority, let's say that the vote is 5-4 and you think that you're going to lose one of your five, then you are going to be much more agreeable to accepting what that justice would like in the opinion. in order to hold the vote. and i think that's -- that doesn't happen just seldom.

i think that happens with some frequency. you have to negotiate in order to hold together your vote. if you have a 7-vote majority, then, you know, if one of the seven says, well, i really don't like that part of the opinion. well, that's expendable vote. you don't want to offend them. that's a vote you really don't need. you are probably going to be less acome baiting to that justice than if it's a 5-4. >> justice lito. >> the rest of them go and right. >> the decisions will be made on monday. >> the supreme court public

information office simply says here's the material. make of it what you will. but we will make sure you have the material. and that's an enormously invaluable function. and it's also very nice not to have the sense that somebody is trying to spin you. >> i personally do go up and like to hear the opinion announceed. i like to hear the justices themselves announce. then i race down to the stairs to the court press area where we all have our lab tops. and a write our first version of that story. so that can get on the internet site. this is much different than when i first started covering. you'd take all day to digest an upon, get people's reaction. now readers really want to know as soon as possible what the court ruled and potentially what that might mean. >> my sense about the press and the corp that we are in the

early stages of perhaps really profound shift in which the press attention to the court, the press awareness of the court is going to be so much smaller over time. that maybe the american people will in time find the court even more of a stranger to them. the newspaper industry is something that's probably not going to be reversed. one cannot imagine an economic model that will keep that immediate yum viable or restore to its former providence. and any foreseeable time in the future, given the changing nature of electronic media in that country.

and so the question arises, who will be the product learned of the supreme court of the future? who will tell the american people who their supreme court is? what it's doing? where it's going? who's on it? who will be paying attention in order. i'm not sure i know the answer to that. so some degree, the electronic media as it is and as it will develop over time can take up the slack. but the pressure in the electronic media for constant, 24-hour coverage enhances the importance of brevity. and in covering the supreme court of the united states, brevity can be the enemy of clarity. >> has the new media made it more difficult? it's made it more challenging, and it's also made it more exciting. if we don't do it this way, no

one will be reading up. if i wrote simply that the court ruled 5-4 in a certain way, who would care? because everyone would know it by the time they woke up the next morning and got their newspaper. what they want to know at specially 10:30 or 11:00 is how the justices ruled. they want something more analytical for reactions from others about the opinion. >> there have been critics of the media who say the press corp of the court is essentially there on bended knee or only there we're a part of the institution we've become for. we treat the justices as if they were untouchable gods and that sort of thing. well, that kind of criticism simply misunderstand the role. the press. but even though we are -- we try to be as detached as we can be from the court and the court is

from the political whims, it doesn't hurt, in fact, i think it helps enormously, for a reporter who's covering the court to be aware of the atmosphere, to have some sense, not some sense of simply being, you know, an apoll gist for the court. -- an apologist for the court. >> in the future, i think they may be ahead of the country. but in terms of technology, in terms of those old quill pens, they will probably always be a little bit behind the rest of us. >> a lot of people say it's secretive. no, it isn't. it's an institution that does most of its work in the open. and as they like to say, the

work comes in the front door and goes out the front door. >> you're watching c-span's america and the courts. we continue with our encore presentation from c-span supreme court week with two attorneys who's argued numerous time before the high court. former general drew days and appellate attorney mahoney. >> mr. roberts will hear from you now. >> mr. chief justice, may it please the court. after punishing with halper -- >> do you remember your first oral argument? >> oh, sure. a case called the united states against halper. i was very nervous when i did my last as well. i think if you are a lawyer and you're not nervous, you don't

understand what's going on. >> your certainly in the moment. it's all about fielding those questions and using the time strategyically so that you respond to the questions. it's essential to answer the questions. >> i have no awareness of the courtroom, the people in the courtroom, any physical movements that may be going on. it's really quite remarkable. >> in this program we talk with two honors who have argued numerous cases in front of the supreme court. they will take us through the experience of oral argument in the courtroom, and also how and where they prepare for this crucial one hour that can potentially sway the justices. we begin in a room just down the hall from the supreme court chamber. where attorneys gather immediately before oral argument. >> in the lawyers lounge, the clerk of the court and usually the deputy clerk come in. and they give practical pointers. they try hard to put people at easy. it's a fun place to be before going into the courtroom. because there's a lot of come --

camaraderie. but it is friendly. >> it's designed calm lawyers down who are doing their arguments for the first time to make sure they aren't funny, or attempt to refer joke or not refer to their familiarity with one of the justices. indeed, they will survive the experience. they ought to see it as the place they can make their best case and the court will hear them and they will get a fair decision. >> we want to enter the courtroom prepared and ready and both sides have an equal chance of it winning the case. the attorneys are instructed to be there at 9:15 in the morning. the regulars all know to be there. sometimes you don't know each other. you don't know your opponent. it might be new york and california. it's not just a bunch of attorney that is hang around the

house. a little different. they exchange greetings, go over the events, let them know if opinions are coming down. the absences of any justices who might be recused. answer any questions and offer them cough drops,s aspirin, anything like that to make them feel more comfortable. the attorney feedback is they like it very much. >> the honorable, chief justice, and social justices of the united states. oh, yay, oh, yay, all persons are admonished to join me. god save the united states and this honorable court. >> when you are sitting in the chair getting ready for them to argue, they come in from behind

the bench through the curtains. they are called in by the marshal. it is a very formal entry. and everyone rising, of course, to show respect. and then they -- the gavel is pounded. and, you know, people sit down and the court is called into session. it's a very -- it's -- it's always always -- very ceremonial. the building is majestic, the procedures of high ceremony, very traditional, nothing sort of informal in the modern about the way the court conducted it's proceedings. very, very traditional. but i like it they way. i wouldn't change it. i have never heard an advocate say they'd like to see the court proceedings modernized. it instills enormous respect for the institution and processes, a lot of reverence for the court. >> we will hear argument today

in case 07290. >> it's a powerful experience. i think everyone feels it. even people who have been before the court many, many times i think still get a rush when that happens. in fact, one the lawyers on my staff, quite a good lawyer. and i went to him, in fact, when i was fairly new in the office. i said, how do you feel when you argue, do you have butterflies? he said, i do. but this is a big guy. but i decide it's like playing ball. i said, what do you mean? >> he said you're nervous until the first hit. after that it's fine. >> when your first argument arrives, i think the uniform reaction is i can't believe i'm here. beyond that what i remember was enormous pressure to perform. that's what i feel every time i'm there. it was pretty most intense the first time.

i understood when i didn't do well, i probably wouldn't get to go back. it is the for many lawyers, an achievement of their career. >> mr. days, we will hear from you. >> i don't know what you call intimidating. it certainly creates a certain nervousness on people who appear before the court. my recollection is i argued a voting rights case before the court. and my opponent was not particularly skilled or well prepared advocate. so i got the sense that the court was reaching out to help him. and i wanted to know why not me. but ultimately, i won the case. and one of the things that i remember about that period was the different rhythm of oral arguments when chief justice berger headed the court. they were fairly relaxed, one had the full 30 minutes. justices held off on their

questioning for a while. at least to let you get in five or so minutes of your argument. then the questions began to fly. when i argued under chief justice rehnquist tenture, the rhythm was quite different. he ran it kind of in a military way, if you got 30 minutes. when you got to the end of your time, if you are mid syllable, he would say thank you, general days. and that was the end of the story. so i had to get accustom to that difference. and now under chief justice roberts, were back to, i think, a more relaxed sense in the court. i think because chief justice roberts was an advocate before the court a number of times. i think to the extent that he's allowed, he identifies with those that are standing up and arguing cases. maybe they should be allowed to finish their sentences before they are told to sit down.

>> it's important for lawyers to be nervous. because an write it shall -- anxiety, i think, helps to performance. it's like being an athlete. having some anxiety before the meet begins helps you to perform at your highest level. that's what you want to do. i feel that way about other courts too. you want to perform at your best. it helps with the development of the law. if the justices and advocates are prepared. if you deliver a performance that will help them do their job and hopefully help your client win the case. >> when you look the the courtroom, you don't walk very far. it's just a few inches away. you are seated next to the podium. you stand up and slide over a few inches. for me anyway, it's about taking a deep breath and saying mr. chief justice. the 10th circuit in this case

correctly held that stone could not share in the award given by the jury unless -- >> and then you are off. and then you have a few sentences usually that you have chosen to deliver the court. but you will start getting questions, you know, usually within the first minute or two with. >> each of the justices has their own unique style about questioning. we have some people who like, you know, the rapid fire style. others who like to spin out long hypotheticals. >> i don't want legalism. i just want the conclusion. a minute has passed before he says yes. has that changed everything. >> would you explain again why he was irrelevant that the gun was operable or not? >> what if the government said in order to run your hospital you have to disclose certain facts? otherwise, we're going to shut it down. >> there are nine people up

there. i'm with them. and we're talking. this is a conversation. and i really have no awareness of the courtroom, the people in the courtroom, any physical movement that may be going on. it's really quite remarkable. there is the physical closeness, proximity. and there's also something about the p.a. system in the court. which is very, very sensitive. and so, from the justices, if they whispered, one could hear the questions. and some lawyers have a real problem. even pros. even once in a while look down on their notes, or being attentive for a moment. and they forget where the question is coming from. because it could be coming from any place. and particularly when justice o'connor, justice ginsburg came

on, there were two women, it would have been a question from o'connor, and they'd say no ginsburg. when o'connor left, they gave out t-shirts that said i'm not sandra, i'm ruth. the other one said i'm not ruth, i'm sandra. just to remind the lawyers of mistakes that have been made during the arguments. >> how do you single this out, how are we certain that there's an injuries to your client that she wouldn't have experienced for other reasons? >> well, your honor, first of all, -- >> it's very intense. that's what it's really like. once you start, you are certainly in the moment. and it's all about just fielding those questions and using the time strategyically so that you respond to the questions. it's essential to answer the questions. you can't persuade a justice if you don't answer what they have asked. but you also have to remember that you have a limited amount of time.

at most you are going to have 30 minutes. often the argument may be 10 or 15 depending on whether you had to split it with another party. so you have to cover a lot of ground in the time that you have. so while answering the questions, getting across points that are responsive, that are also helpful to you. but do it in a way that -- where you still feel like you have addressed the concerns that have been expressed by the justices. >> there are some question that is are real questions that justices want to know the answer to the question. something that has been on their minds. other times, they are talking to a fellow justice through you. you are kind of a dummy, and the justices have already got to know something about their fellow justices use on the issue. and then they'll be back and forth. and you'll be pushed. one of the things that the justices do is take your argument and move it to the next level.

and the next level after that. because the court is concerned with resolving, not only the case before it, but thinking about how their decision will affect similar cases or related cases down the road. what will be the impact of precedent? and so one of the answers that is often given but it not helpful to the court. but you just can't -- you can't restrain yourself saying but that's not this case. and usually one of the justices will say, we know that. that's why we asked the question. sometimes it's not so blunt as that. so the argument goes on for a while. and one of the bad signs of an oral argument is when the questions stop. it means that, you know, you've either not persuaded them or they've figures it out already. there's nothing more that you can add. you've been so persuadive they don't need to hear further.

but then you sit down and their respondent's lawyer gets up. he or she has a job of setting out that argument. but also trying to poke holes in the argument that the made by the petitioner. >> well, it's very different. because it's not made for tv. and so the antses that you are giving are usually not wonderful sound bytes that the press would love to report and audience would love to cheer over. they are really designed. it's much more scholarly exercised than what we see on television. it's designed to persuade them that based on the facts in the record and the case and the press sent that the court has to deal with or the language of the statute to bring those, all of those materials to bare in a precise and persuadive way. and to do it in a very small amount of time. so you have to be extremely well prepared if you are going to do well. you have to know your case

backwards and forwards, inside and out. you better know it better than anyone in the courtroom. you have to be able to recall is quickly and weave it into a narrative that you are giving to the court. it's very challenging. they are -- they are all brilliant. americans should be enormously proud of their court. i mean the supreme court is excellent. and all the way across the bench. it's very challenges for advocates to argue at that level and meet their expectations. very challenging. >> a critical mass. >> i don't think so. >> 4%? >> you have to pick some number, don't you? >> well, actually -- >> 8%. does it stop being a quota because it's somewhere between 8 and 12? but it is a quota if it's 10? >> a lot of people have the impression that it's a dog and pony show.

what can somebody tell me in half an hour that's going to make a difference? and the answer that it is probably quite rare -- al a though not unheard of, that oral argument will change my mind. but it is quite common that i go in with my mind not made up. i mean a lot of these cases are very close. you go in on the knife's edge. persuadeive council could make the difference. >> ordinarily, yes, you get peppered within the first minute or two. used to be within the first 20 seconds. lately, they seem to be giving advocates more time. yes, you can get questions from any justice at any time. and your job is to answer the questions. it's not really about coming with a prepared speech. most of the time that i spend preparing for argument is spent preparing for anticipating the

questions and preparing answers that i think i would like to give to those questions. sometimes that involves thinking of hundreds of questions that they might ask. even though they'll -- probably not ask you more than 50 or so in the course of the half an hour. i once had an argument where i think they asked 56 questions in 30 minutes. so it's a lot of questions. yes, they interpret each other even. in fact, there was one time when i was arguing. i don't remember what case it was now. where the chief justice who rehnquist at the time. i was answering the question from one justice and another justice. one justice came in and asked another. let her finish her answer. which i thought was a great day. because it was in effect of the chief umpiring for me. and i think, at least my reaction to it was as if he has said she's worth listening to. so that was a great day for me. >> i think everyone in talking about whether one focuses on a

particular justice. i think all really skilled advocates before the court and even novices understand that they ought to be familiar with the views of the justices, the respective justices based on what they have done in related cases. and be prepared to recognize questions that daily are the result of the set of positions that a justice has taken. but i think it's not a very smart approach as an oral advocate to seem to ignore the other justices and focus physically on another justice that may well be the justice. i don't think the justices like that very much. they are not thin skinned. i don't think their egos are boost by that. i don't think that's a good idea. very surprising things happen. i remember one of the early cases that i argue the, i was convinced that justice stevens

was with me every step of the way. he was asking great questions. he was looking benignly at me as i argued. i even thought there was a nod. the opinion came out it was 7-2 he was one the dissenters. and indeed i wrote a lower view article about the issue that i was addressing in the lawsuit. it essentially said don't take people for granted on this issue. justice stevens wrote a dissent that it's kind of a road map of how legislation and how administrative actions ought to be taken to just steer clear of some of the problems that he saw in the federal statute that i was defending. >> often when we are preparing, you can't be sure which way the argument is going to go. so you'll have fallback sort of positions. the argument that you'd love to win if you could get the votes, and you may see early on that that's not likely.

so you need to fall back to a position that's more likely to garner five votes or six votes. and sometimes you'll have to make that judgment early on in the case. but that's not completely changes strategy. it's typically something that you've thought about in advance. >> how well do you have to know the style of each one of those justices up there as you prepare? >> i don't think -- i think it's helpful. and the more you know about the court and about their precedent and the they they do their job, certainly the more of an advantage. i think there are many advocates who show up for the first time who've never been to an argument before who do a wonderful job. simply because they've mastered their case. they have anticipated questions without knowing precisely what questions justice breyer might ask. >> she was not engaged,

particularly where the government argumented, told the jury that nancy was of the central figure in this episode. >> how do you know it's not affirmative defense? >> well, it doesn't read like -- >> it is often difficult for the public to understand what is happening at arguments because the issues often tend to be very complex. and they are often the issues are about often about statutory interpretation. and so they are short of unraveling different words in the statute and talking about the enactment history and how of different sections of the statute intercept and maybe how they -- how they interact with other federal laws. and so i think that a discussion of that type is difficult for the public to follow. there are other cases that are easier and easier to get their arms around. and certainly, i had a case about recruiting 8th grade athletes.

and first amendment protections that would apply in the recruitment process. and a lot of that was really about the potential for a coach to undually influence an athlete by making calls to the home. i think a case like that people could listen and nod their heads about what was happening more. it white light will go on when you have five minutes remaining. and when your time has expired a red light goes on. and in the supreme court when the red light goes on, you are supposed to stop. when chief justice rehnquist was presiding, you were really supposed to stop. >> i wanted to address some of the issues that were just raised with my opposing council on the issue with respect to the eerie issue as well. first of all, -- >> does it matter to you whether you win a case 5-4 or 9-0 or

8-1. >> i think a win is a win. looking down the road is the question is what presidential value does the case have. does it leave for another day the same issue where you have very closely divided court? there's situations where there are issues that one wanted to have really nailed down that don't get nailed down. but i think as one of my colleagues said, he'd rather lose 9-0, because if it's 5-4, you'll always think, what could i have done to push one justice over to my calling, to my column. i think those are the ends. 9-0, nothing you could have done. 5-4, there was a point where you might have been able to shift one vote. my sense has been that even when i was unhappy with the courts

decisions and had for a moment the -- i was robbed sense. the supreme court is so impressive to visitors, particularly people from other countries. but also american citizens. when they walk into that court, i think they get the sense that these are very serious people who understand the weight on their shoulders, who are trying to do the best that they can. and i love to take people from other countries into the court, and just have them watch smart people asking probing questions, and trying to find helpful answers to the issues that are before them. >> they are not in the mysterious body. i don't know why people would view them as mysterious. it's true they don't get to see the proceedings on television, something that i really welcome, because i don't like the idea of everything being televised.

but i also think it's great for the justices. because they continue to have -- they don't have to be the same public persona that someone that was on television all the time and is quickly recognized. i think it has that advantage as well. but i don't -- i don't think of them as mysterious. yes, they deliberate in private. but that's true of all courts. there's really no court that i know of where they do their deliberations in public. so i'm not sure why they would be regarded as mysterious. they are not. they are excellent at what they do. their decisions are all public, obviously. the proceedings are public. people can come if you want. you should come to see the action and building in person. >> i think the supreme court is generally viewed by the american people as an institution that is worthy of their respect and trust. and we have things like bush versus gores where there are

figures. but i think all in all, they tend to pass. one of the great things that we've been able to look to, the civil war notwithstanding is that through very, very difficult times we've been able to keep justice in focus. and to understand that that's a value that we can't thread upon. we can't undermine. and, of course, there are ups and downs. i don't want to speak for the entire sweep of history. but i think the notion is wherefore we happen to be if we feared, if we've perhaps left the path of justice, we have to find our way back. because that's the only answer to a meaningful and constructive future. >> you can watch all of the interviews from c-span supreme

court week special. as c-span.org/supremecourt. or go to c-span.org and click on supreme court under the web site link. join us next week for america and the courts saturday evening at 7:00 eastern on c-span. >> the health care debate as resumed today after more than a week of quiet following senate passage on christmas eve. the four relative house chairman meeting with pelosi in the speaker's capital office to start setting the parameters. speaker pelosi and house majority leader hoyer will head to the white house with president obama to discuss the final bill. that's according to the democratic officials. also today president obama will announce new measures to tighten up airline security after the failed christmas day attack on

u.s. jetliner. he's holding a meeting with 20 government officials who have been tasked with carrying out reviews following the botched attack. secretary of state hillary clinton, janet napolitano, and robert muller all among those who are attending. after of the session, the president will address the public that statement by the president coming up at 4:00 p.m. eastern. you can watch the president's remarks live on our companion network, c-span. :

>> good morning everybody. welcome back to the 2009 kaplan conference at the university of virginia miller center. bicester's conference is for debt and deficit. yesterday we learned about the use and abuse on fiscal growth across countries and states. we learned about global balance as, exchange rates, in the global dimensions of u.s. debt. today we turn our attention inward and score policies and associated attempts to handle health care expenditures in the

possibility of designing legislation to deal with debt and deficits. we will continue our wide ranging discussion and i want to remind the audience and the participants of a few ground rules. first, our presentations are intentionally designed to be sure to facilitate discussion among panelists and with the audience. when our moderator decide that it is time to open the floor to question and answer, those of you who have questions please go to the back of the room where ashley will be holding a mic and she will allow you an opportunity to ask questions. the second reminder is that if you have cell phones, blackberries, iphone, anything electronic other than a peacemaker, please turn it off. the signals from those interfere with our tv, our mics, etc. i will pause for a moment why that happens. i feel like were getting ready to board a flight take off.

our first session for this morning is entitled writing a prescription for reform and it features three panelists. we lost one unfortunately two-family complications. our panelists include thomas rice was the vice chancellor of academic personnel at the university of california los angeles and he is a professor in the department of health services at the ucla public health. jonathan skinner is the professor of economics at dartmouth and he also preserves as a professor with the dartmouth institute of health policy and clinical practice. our third penalize is eric patashnik. he's a professor of politics and public policy into the associate dean of uba's patent school of leadership and public affairs. our moderator for this panel and the next is alan murray who is the deputy managing editor in editor of "the wall street journal." >> thank you, david. so each of these gentlemen is going to make a presentation of no longer than nine minute.

if they do go longer than nine minutes i encourage you to start fidgeting or wrestling or newspapers. and by the way, at least two of you are reading the right newspaper to russell. i did see "new york times" back there. we can live with that. for presentations of no more than nine minutes and then a discussion among us and it will open the floor to all of you and tom is going first. >> thank you very much. i'm delighted to be here and i'm glad they were talking about health care costs are because that certainly is an important part about the debt, which is the focus of the conference. i'll be focusing on what type yours are in my opinion responsible for the high and the quickly growing health care costs in the united states in an unjust and briefly with some thoughts about how this fits in with health care reform. and i have only two slides. the first slide shows you how much of an outlier the united states is related to health care costs. now you may think that we spend a lot because we're rich, but that's not the case at all.

what we have here on the vertical axis is how much the country spent per person on health care. and on the horizontal axis we have how rich the country is for the gross domestic product. if you put a line between the two, but you find is this one variable, how rich a country is, pretty much explains how much every country spends on health care with one exception, the united states. when we talk about the u.s. spending outlier think this is really what we are talking about. the u.s. spends about twice as much per person of other countries do one health care. and if you look at number two, switzerland, where 56% higher than the swiss. so why are costs higher? will be focusing on this and there are many factors. there is economic, political, historical one for him to relate. it's hard to come up with a short list but at the risk of doing so i've come up with a list of four reasons why think that health care costs are higher in the united states than elsewhere. and the lack of consolidation of

purchasing power, medical technology and specialization, paying for unnecessary care him and fee for service medicine. and i'm only going to talk about the first one and do the others at the end because john will be talking about the other three enhanced talk. understand lack of consolidation, purchasing power, take a counterexample which would be canada. as you know canada has a single-payer system. there's only one buyer of care in canada. that's the problem says so they are what we call monopoly on the buying side. so they have tremendous power in the negotiations with hospitals and doctors and pharmaceutical companies. and they didn't always have this. they're the 1960's they were like the united states about a private insurance. they actually spent more than we did on hospital physician care. since that time, since they consolidated and got involved in the purchasing services, the growth rates and cost have been

much lower than the u.s. cost. but that's probably not a good model for the u.s. i don't think the insurance companies are going anywhere. so what we need to do is look at a model that involves insurers. and there are many models out there that are much more effective at controlling health care costs. one example, for example, would be -- would be free of. france has multiple insurers but the government does the negotiation and the coordinating of the crises that they paid to hospitals, doctors, and pharmaceutical companies. germany doesn't use government as a consortium of insurers that they call sickness funds that do their own bargaining and then they pay, and rates to providers. so to me the key is to not have one buyer as in canada, but have multiple buyers who want to think to be true. you want payment to be cord needed between the insurance companies were doing the purchasing and you want the

insurance companies to the nonprofit spirit that's obviously something that we don't have and we are unlikely to have so it's even tough for us to control costs here. i should mention this as a safety valve. other countries to allow people to often buy supplemental coverage. yet, greater benefits and that's probably necessary for political stability although odyssey takes away from the equity of some of. there's some other advantages for this coordinating of buying. one is that providers have an incentive to choose one patient or another. right now medicaid patients are worth much so doctors don't want to treat them in their offices. that's not true under a system like this. also, there's no opportunity to cross shift. everybody's been the right amount for their patients, so one player isn't taking advantage of another payer. we do have one example where we take advantage of the power of the buyer and the va system. some recent research indicates

that the va pays half as much as private insurance plans pay under part d of medicare for prescription drugs. they are taking advantage of their purchasing power. and we're reminded that private insurers in part d of medicare is and does affect to say the va, which does take advantage of its market power. let me just talk for a moment i private insurance. we rely on private insurance here. it's for-profit insurance and i do think elite to much higher health care costs. david insurers, obviously by definition, they have to make a profit. in addition to that they engage in marketing. they also engaged in medical underwriting. they have to hire a lot of actuaries basically to try to make sure that they are not taking on people who are too expensive. these are all very costly things, so that raises the price of private insurance. in addition, they said they do not have as much bargaining power so they also can't keep their prices low by taking advantage of consolidated power

that i'm talking about. why do we allow private insurers to have monotony and the answer is that there's no reason to think their savings that would be transferred to the public. what you really need i believe if you're going to have insurers plainest middleman would be nonprofit insurance. we don't have that in the u.s. and i do think that's one of the key reasons were more expensive than other countries. salome just then with a few thoughts about health care reform. as you know the current proposal before congress really do very little to control health care costs. i'm going to argue that that's probably a short-term strategy and i know people will be disagreeing with that. if you just look at my site here, the proposals do nothing to consolidate purchasing power. a caveat to the public option in all talk about that in a moment. they do very little to do with the proliferation medical technology. they do very little to try to get back oeste make primary care. in terms of name for unnecessary

care and fee for service medicine, john will be talking about these sorts of things. there are some nice things in the bill that talk about movement toward accountable organizations, moving away from fee for service medicine by bundling payment, not paying for unnecessary care given incentives to provide better care. it's either going to probably start the pilot studies and it's going to be a very rocky road to get from the research evidence to wholesale changes in the u.s. health care system. in the short-term, i really don't think that we're going to be doing very much to control costs. but as i said, i don't think that says unturned this is -- when you want to mention is one finger and just in doing is more research on comparative effectiveness, what things work and what things don't. and eric is going to be talking some about that. when congress gave about a billion dollars for comparative effectiveness research it said that we couldn't look at the cost. we could only look at the

benefits of this. this is something that my colleagues in britain and australia look at benefits cost fund is nonsensical. how are we going to choose the most cost-effective things if we can't even be looking at the cost, but there is a political decision that congress made that it's really going to sign us as we go forward. so anyway, why do i think that putting cost aside now might be a good idea? i think it's to build a political constituency, you really can't talk too much about cost control your cost control is not a mom and apple pie thing. every dollar of cost to save is a dollar of income that you are taken from someone to try to put together a critical constituency that's really not the way to do it. i think what we should do is probably what medicare did in 1965. it basically was a christmas tree at the very beginning. that's how they got the legislation passed and therefore legislation was passed they started putting on restriction. and in fact, we must do a pretty good job because now everyone is so scared that medicare pays a

little that we can't be using that as a model because it's just too stingy in its payment. so we did put in our cost controls later, although it still be here in medicare does have an certainly has its financial problems. salome just end by saying i think the public option would've had the potential to be troll cost because they could sell insurance less than private insurers do. it would garner market share. that could allow for the consolidated purchasing power attacked about to reduce costs, which would bring more buyers they are. reading the newspapers it doesn't look like were going to have much of a public option as part of the political compromise, that would be one way which we could receive health care reform have been some potential for controlling costs. so if we could just end on a positive note, not really about cost or dead. i think as we move towards universal coverage, we're going to be creating a system that will be a more malleable to the

changes we want to see with regard to cost and payment. but to get everyone under the same umbrella we would have one system would make it much more possible to control costs. >> tom, thanks. before we went to john, let me ask you one question. when you talk about consolidating purchasing power or monopolistic buyers, you're basically telling us about price controls or something very close to price controls. i guess the question is, we know that can lower costs. but what would the effect be on innovation, on quality of care, etc.? >> sure, so we have a nice natural experiment because almost all of the countries do exactly what you're saying. and let's take the case of germany. germany is a system that spends far less than we do. there are medical outcomes appear to be better than ours and they don't have to wait for services. when actually waiting in time for services in germany as a little bit lower than the united

states. other countries that i talked about, france, also have excellent outcomes. so i don't think that jill necessarily be sacrificing quality. commonwealth fund has done a service of six countries is a combination of serving population and surveying physicians in the country. and they've ranked each of the countries with the six different elements. the u.s. comes in last altogether and comes in last and most of the six elements in terms of quality. canada came and said. it's the other european countries that tend to do better. so there examples of price controls on my novelistic power word appears that they can pull it off with a system that provides high-quality care to lower costs. >> john? >> thank you. let me switch over.

i'm delighted to be back to charlottesville. university of virginia gave me my first job and i had a truly wonderful time here and some extraordinary students. it's nice to see students here also. such as eric amah for example, who wandered into my class and realized that the drop date was too late so we had to stick it out. it really made for a wonderful am a wonderful time. i'm going to talk a little bit about the quantity side. thomas talks about getting price is right which is something that congress likes to talk about. but i'm going to also look at the quantities, how much health care we are getting into the right amount. and it may involve different solutions to getting the quantity right. prices matter, but they may not be -- there may be other ways to get there. so first of all, i just want to make this observation. if you check to most economists have quite health care costs are in?

why is -- why are health care costs imperiling the fiscal soundness of the united states government going forward for the next 20 or 30 years? bill give you one answer. it technology growth. technology growth gives us good innings, but it also costs more money. but my usual response is to go back to an early debate about gun control were people used to say guns don't kill people, people kill people. what i'm going to try to convince you that it's not technology growth, it's the self that causes health care costs to grow. it's the people who use that technology. it's the rate of diffusion across the population that really effects the growth in health care spending. what i'll show you is that there are different regions in the united states in different countries in the world that has dealt very differently with that kind of growth. and i'll show you some pictures. here's one from an earlier article that shows regions in

the united states and i pluck a little bit more from the dartmouth outlets. and it shows the change over time and spending between 1992 and 2006. these are adjusted for inflation in per capita spending adjusted for age,, and race in the medicare population. and what you see first is i'm sorry but the type is a little small. the orange curve on the top is miami which is a very special place started high and grew at a faster rate. but the place i want you to notice is the one we're looking at in particular, the san francisco, which is kind of a yellowish color. in their growth rate was only about 2.4% per capita during this time. compare that to 3.5% growth rate of the -- in the national average. in the idea is that if we can figure out what it is that san diego does that san francisco does. even the ellis says that the

rest of the country hasn't figured out with regard to restraining growth that we can basically get medicare back on at least an even keel for the next three decades. and if you run the numbers out, that is if you say okay, san francisco 2.4%, united states 3.5%. that's the difference of 1.1%. it seems small, but that difference grows over time here at this as something economists teach their wonders or the horrors of compact interest. it's a difference as you can see between current projections, which is the blue line, for this sort of combined medicare deficit or debt i should say. versus what would happen if we manage to slow growth by one and a half%. it's dramatic very and that the key to getting health care costs under control. it's not some -- something that's never been done anywhere in the united states. in fact, it has been done we just have to learn from how they do it. and to provide the right incentives to do it. right now medicare has no incentives to reduce growth

rates. in fact, they will pay for anything that doesn't kill you. the second observation is that it gets back to something that's herb stein, president nixon's economic advisor used to say and her beach to teacher for a couple years in the economics department. and what he said is that unsustainable growth is unsustainable. so health care costs cannot grow without limit. the current production said that they will account for more than 100% of gdp. if they grow at the same current rates by an -- within 17 years. that's clearly not something that's going to happen. but we cannot do other countries to see what has happened. and i want you to not come again, this gets back to my earlier point about how different countries have dealt with technology growth in very different ways. and explain to you what this number is. the number on the left-hand side of the change in spending on health care as a% of gdp.

so you see that u.s. is that the right. that's seven. that means in 1980 u.s. health care spending was 9% of gdp and i'm sorry in 2007 at 16% of gdp. so the difference is 7%. you notice that the left-hand side there is s. w., d. is denmark. both of them have not grown in health care by more than 1% of gdp. they have sustained that that is a sustainable growth path for those places. the question is why sweden? why denmark likes why germany? why the netherlands as opposed to the u.s.? are some hints that this is a scatter diagram and shows as before the change over time in gdp on health care spending and again you can find u.s. in the upper left-hand corner which is 7%. and you notice the sweden and denmark on the lower right-hand

corner down below, 1%,. the key is that sweden and denmark started with a high tax rates in the 1980's. you can't raise taxes much beyond 42% of the economy. it gets very, very, very inefficient. you can show this theoretically but you can see this empirically. their natural limits of how much you can spend on health care. it's a very unfortunate way to do it, but it will happen. and i think everybody recognizes in order to basically feed health care you have to raise taxes. there's really no other way. i think that sooner or later you're going to start reaching limits that the united states is not comfortable with. >> u.s. two more minutes. >> okay, the third point and this is something getting back to tom's points as well as that there's lots of than efficiency in health care. and i promised a map.

he is the map of dartmouth's referral regions. miami as i noted that the country and spending, $16,000 per person compared to places like grand junction, which is about $6500 per person. and so, there's a lot of money going on. in fact, if you counted up the lifetime difference is in medicare expenditures between los angeles and minneapolis or miami and minneapolis, you end up with a really nice car. this is used. i mean, it's $80,000. it's yellow and italians would never drive a yellow ferrari but nonetheless this is a lot of money. and this is part of the idea of the potential savings. your oars back, office of management and budget has also identified us as potential savings at sun could go back to the residents of los angeles. but other parts of this money could go back to the government to fund health care reform. and to give you an idea again of

quantities, these are stance which some of you may be familiar with. their operations with which reduced blockage of arteries of the heart and you can see that each dot corresponds with one of the region in the united states. it's kind of like a histogram. sorry for the statistics, but on the left inside you see rates for thousands and there's one that's an outline. it's way, way up there. it's a leary, ohio, it happens the college. nobody knew about this until dartmouth was identifying these folks. we need to do more of this. and just for comparison services this is the estimated rate in canada and team in the general population. in other words, there's a lot of potential savings. you wouldn't necessarily pick it up with comparative effectiveness unless he really started monitoring quantities than what doctors did in different regions. and again, thompson mentions the q. organizations. the idea is that it's the

doctors who decide, not the panel in washington, not some insurance company. and the idea is that these doctor or hospital groups are paid on the basis of how well they restrain growth in costs. and so, this is the scenario we'd like to have play out, rather than rules from above that the physicians in these groups get together and they say, wait a minute, g. i. here are spent rates are really, really high. they go down with internal medicine docs go down to the cardiologist and say look, what's going on here? your rates are the highest in the country, why is that let's take a look utterback kurtz. let's try to get costs down. the works internally and that's the way i'd like to see the direction of health care reform. more toward these accountable positions. >> john, one question that tom answered in his comments. do you see anything in the current bills in the house and the senate that are going to do much to deal with the problems you just outlined? >> i agree with tom here. i think they're trendy set of

frameworks for these kinds of organizations. and the language is actually in the legislature, but in some cases they are pilots which i think are necessary because we really don't know how to roll this out across the whole country. the greatest disaster would be to do things too quickly and to have them not work in them for people to reject the whole idea. >> so in other words, it's not much but it's a good first step and maybe incremental small step. >> is a good first step. the way i see this is a must return to the prices right. and the long-term, restructure the way that health care is practice so that people are more integrated groups. >> eric? >> thank you. so the rapid increase in per capita health spending the united states would be much less worrisome if we thought that every dollar was contributed to better outcomes. the strong reasons to believe however that a large share of u.s. health care spending is wasteful and inefficient. and wasteful spending persist in

part because we don't have good, mechanisms for identifying it. the u.s. health care system often adopts the testing treatments and technologies even if there's no objective scientific evidence that suggests they are better than available alternatives. as tom mentioned, congress and the obama administration has been supporting increase spending on what's called comparative effectiveness research to generate reliable information about what treatments work best for what patients. in the hope is that better information will help not only reduce cost, but improve quality. in other nations are to using such information to some degree. but as the recent controversy over the guidelines reveals efforts to use medical evidence to alter treatments were testing protocols can develop into a political fire story. it can lead to tremendous backlash among providers, patient advocacy groups. but a question is what does the general public elites about medical evidence? this is a pretty new issue in

the american political debate. we don't know that much about how ordinary set us and think about it. will the american public about evidence-based restrictions on terror or coverage and what are peoples biggest fears and concerns about this initiative? to try to get at these questions, my research partner, alan gerber, a professor of political science at yellow. i recently conducted a political opinion survey to want to shed apollinaire results of the today. they are hot off the press if you will. they are subject to revision, but we think our results are sharp and ambiguous enough that we feel confident in sharing them. so here are some key findings. first of all, the public expresses some support for the concept of evidence-based research and the medical spending, but it's clear the public does not fully understand this problem. large majorities of the public are convinced that research on the relative effectiveness of different treatments won't be useful in the treatment guidelines are vulnerable to corruption and abuse.

lots of groups in society, all as everybody, is worried about this. the two groups that are masterful are republicans and senior citizens. they are particularly skeptical of guideline steering it could lead to rationing and to interference with the doctor patient relationship. if we asked people who should be deciding if new treatments of technologies are better than current ones, the public has the most trust in a panel of doctors and citizens and the lease trust and independent government agencies. the public thinks the new treatments are generally better than old ones, but this last one i think is a little interesting. there seems to be some poor to be willing to accept cheaper treatments at their own doctor recommends them. and so let me show you some graphs here to highlight this. first of all, if we asked people, do you think that it's okay for medicare to pay for new treatments and technologies only if they provide better results than current treatments of a large majority of americans say yeah, i think that's a good idea. i think medicare's only spend money fare better.

but if you ask them the statement in your something i think the vast majority of economists researchers would agree with that hard evidence is often unavailable about which humans work best for which patients. and this is something that fed to and others have been talking about. only 41% of this public think this is mostly or completely accurate. there's a lack of understanding of this problem. order 1% of the public say this is either mostly or completely or almost completely inaccurate. the next question, if we begin to give the public some of the reasons both pro and con about the research received advocacy groups, the vice manufacturers. we want to test which ones resonate with the general public. what we see a dozen of the arguments people are making against comparative effectiveness research really do have a lot of traction among the public or at one of them is the research will be useful because

medical studies focus on the effects of treatments for the average commission and every patient is different. so people feel their individual and the studies will be useful for them. there's so much variance. everybody has their own health history. the next question -- the next argument against comparative effectiveness research that also generates a lot of support is that these treatment guidelines are not going to keep up with the pace of medical innovation in the not going to reflect the latest scientific breakthrough. somehow they're going to be obsolete as soon as they're formulated. 73% of the public lisa. and here's one i think we're beginning to see some of the fears that the public has. and the government and private insurers are going to use research findings to influence treatment by interfering in the relationship between doctors and patients. it's very clear that americans care deeply about having a personal relationship with their opposition. you can see even a majority of democratic voters have this concern.

republicans who agree strongly or agree somewhat very, very high percentage of wealth independence. another fear is this idea that some entity, some outside entity is going to come between doctors and patients in making treatment decisions. again, democrats either find this very convincing are somewhat convincing and the majority of them at of republicans and independents are even stronger numbers. and if we look by age group, which is interesting, here we see the same kind of concerns about an outside group interfering with this relationship. among all age groups, but especially seniors are particularly worried about this happening. 67% fineness is a very convincing reason to be concerned and 21% say it is somewhat convincing. government and insurance companies will the findings from comparative effectiveness research to ration care. again, this concerns throughout the political spectrum republicans and independents are

more concerned. the democrats are concerned everywhere. and here we asked people -- we gave people a list of possible entities that could -- that could be making decisions about whether new treatments and technologies provide better results. you should be doing this research? who should be making these findings? we gave them a range of possibilities and you can see that the group that people trust the most are a panel of doctors and citizens. university scientist that might rank fairly high among people in this room do not fare as well. the commission of business leaders did very poorly and an independent government agency, only 3% without the most trust. eric, what do you think happens when a panel of doctors and to defend his panel and empowered by government agency? >> good question. and we follow it up with who would you trust the lease to determine whether the students and technologies are better. and you're the independent government agency when by a nose

over commission of business leaders. it was neck and neck there. and we press that one and here's the breakdown by demographic group of how people ranked those who are the lease trust an independent government. the 39% of overall respondents would rank independent government agency the least. 19% of democrats, 62% of republicans, 50% of seniors. okay, part of what's in public opinion. again as i say this is news. this is something that political scientists have not been a lot of timeserving about. try to understand how americans think about the health care system. one thing is clear that people think that the health care is getting better and that new treatments are more effective than those that were introduced ten or 20 years ago. it's very large majority believes that, especially seniors. this one i thought was a little bit interesting, that if your doctor tells you that their are

two equally effective treatments that your insurance will pay for completely. so there's not going to be any financial impact for the patient. would you still prefer the more expensive one? so there's two treatments. one is more expensive, one is cheaper. your insurance company will pay for it. the doctor says they are the same. would you want a more expensive one because you tend to think more expensive things are better. and actually here, the majority disagreed with that and were willing to be for more so among whites than other ethnic groups interestingly. we don't have a full understanding of what appeared to suggest the importance of doctors mediating decisions about cost and prices, how important individual patients what to doctors for guidance. i still watch what they do, not what they say. >> absolutely, absolutely. just to finish up a few other sites. again, trying to prove how americans think about the health care system. 55% of the public on the 59% of seniors, and this one night and

his remarkable believe that modern medicine can cure almost any illness for people who have access to the most advanced knowledge and treatments. we believe in america about medicine can keep this young, can keep us healthy, can keep us alive to a very large extent. 64% of the public believes that improvements in the quality of medical care is the most important reason that people live longer today than 75 years ago. we give people a lot of reasons and that better public health, increase in smoking, better nutrition, lots of reasons. many think it is better medical care why we live more than our great grandparents. [inaudible] well, i don't know about that. the last point here is i think if you asked a lot about the economist, a lot of health experts about why is health care

so expensive? you would come back to the fee for services than in the distortion it creates in the fact that private and specialty groups although of course they care deeply about their patients to act in ways to try to maintain their incomes. is there a recognition that this is really part of the problem? only one in three americans believe that maintaining high income for a specialist is an important consideration when doctors are making recommendations for patient care. >> eric, thanks. you should also feel very fortunate to get an early look at these fascinating members. >> they are preliminary and should stress. >> we're happy to have this. it's fascinating and i think the three of you has made a very compelling demonstration that the current system, if you can call it that, in the united states is indefensible and unsustainable to quote the president. the status quo is not an option. but it feels to me like leaving aside the clash of special

interest at a higher level we are in the middle of a great debate in this country about how to move forward on health care. and one option, tom, is the one you laid out to move to if not a single-payer system, something approximating a single-payer system where you have enough domestic purchasing power and the purchaser uses comparative effectiveness training to decide which treatments to pay for and which treatments not to pay for. that's one direction, single-payer. the other direction is, can we do in the health care area what we have so successfully done in many other areas of our economy and create an actual functioning marketplace where consumers have bundled care that consumers can look at comparative effectiveness studies and say this works better than this or this is more cost effective and i don't want to blow all my savings to purchase this one, create some sort of a system where choice works to keep costs

down and to keep quality up and to satisfy what eric demonstrated is the public's belief that if the government is making choices for them they are going to get stiffed. so i'd like to ask all three of you to comment on that debate. is it real and definitely as he pointed out, tom, nobody else is taking the market model. on the other hand, americans have great faith in the market. if the network to their benefit and airlines and telecommunications in dozens of other industries, why not in health? john, i'll let you go first. [inaudible] >> what is that bikes [inaudible] >> well done. touché. >> i think that's a great question because it really gets to this fundamental question of whether the united states is different from other countries, whether it should either look to other countries for a model of how the foreign health care or whether it should continue to

try to make something that it feels comfortable with the sort of has obvious reasons in the past. and an article in "the new yorker" said if you look at health care reform in in other countries they often draw on -- they don't come up with something plan do they come up with a resisting untrimmed existing structure. my own view is people find it difficult to make market-based decisions at the time of deciding what kind of treatment to get. and i ran into this recently when i was -- got a call from the vet about my cats on whether he wants to spend $600 on an operation that had a one third chance of success. i mean, this cat doesn't even like me and -- last mac i had to make the call. imagine making those kinds of decisions about family members or even about myself. i just don't know how to do it. i do believe that there can

be -- i actually like fast a system where everybody gets a voucher is worth a certain amount of money for their own insurance plan. they can choose whatever insurance plan they want. so it's a single-payer, but it's not single provider. and so if i want to get an insurance plan that tells me advance we're not going going to pay $30,000 for that treatment for pancreatic advanced pancreatic cancer that extend your life by two weeks. and as a consequence, your premium will be less, but you have to agree to that before hand. i would sign up for that kind of plan. tonight and as any other country in the world use that kind of a system? >> i don't think so. so this is kind of new and different and not exactly the way other countries do it -- >> but it's an american market-based solution. >> if you want to go first class, that's fine, you pay for.

>> tom, i'm guessing on your comment earlier you wouldn't agree with that? >> we ration, in our country, and this is consistent with what john was getting out on the demand side. he was saying if he could get a cheaper policy that doesn't cover something that he doesn't think it would be very useful he would choose not to get it. i think countries do their rationing on the supply side. what that means is they don't have as many specials untracked specialist available. they don't use technology as much and basically what they do is brush and on medical necessity than a ability to pay. i think that's a better way to go. i want to get to the question -- >> just before we believe that eric's numbers show that the american public is profoundly disturbed by anything that approaches with a government or quasi- government agencies making decisions on what care they can and cannot have. >> i was in favor of that

government making decisions. >> you were a part of the 3%. >> yes, those are quite eye-opening. but it's getting even greater. i want to get specific with your question about choice. i talked about how i think consolidating market power would be a way to control costs. u.s. about an alternative which is giving consumers more choice. i don't think that works very well here and i can give an example, which the people disagree with me would cite the same example, ballot ringlike i believe it is a good example. the medicare drug benefit gives people a tremendous amount of choice. most people have about 50 different choices of medicare drug plans. and if you try to do it yourself, you try to do it for a parent, you'll see how very difficult it is. i tried to do it with a parent, for example, and it doesn't work out very well. it's very hard to figure out

among 50 plants, which is the best for you. for the program sometimes is cheaper than expected, but actually it's been overcome them. what happens when people make a choice one year, they do not change to another plan in subsequent years. year after year they stick with the same plan. research has shown people can save a lot of money if they switch. most people are in the wrong plan for themselves. those that switch on average could save $500 a year. when you get people a lot of choice they don't have enough information. they don't have the time. they don't have the expertise. they end up making overtime bad choices. so -- >> it sounded to me like you're talking about in other words the choices have to be fairly simple and managed. if there are 50 or a hundred different choices you've got a problem on your hands.

>> but i think tom point is well taken. tivo can get very confused. health insurance is a very complex product. >> eric, i know these are new results and you'll may have a little bit of time to assimilate them. but what do they tell you about how to solve what is really a grand ideological debate on how to move forward on health care? >> i think that the risk of oversimplification there two ways at the system level or at the individual level at a voucher arrangement. the problem we have in the united states is that we've been unwilling to make either choice. what we have done in this country is essentially delegate to physicians and providers. they are the experts. they know what's best. they should tell us what health care we need. and the problem is that what we're finding is that physicians are not very good at controlling costs and physicians often don't really have the information to determine what's best. >> part of the reason we aren't unwilling to make the choice is

because we are greatly divided on a very good question. i just wonder if you think your poll results help us get to an answer? >> i think what the poll results show is that there is tremendous distrust of government. and so for going to have any of this kind of intervention it's going to have to be a new institutional structure that will not be seen as a federal agency, even in the senate bill they're talking about nonprofit private organization. i have concerns about how well this would work but it is responsive. >> who appoints the members of the nonprofit? >> the membership is going to provide representation for lots of different groups including industry and by manufacturers and doctors and others are not so much researchers side. there's a difference between hospital in the senate bill in that way. it really suggest going back to john skinner's point at the beginning. the importance of doctors and changing the culture of physician behavior so that physicians will see results in

their hospital or will see results in their practice and begin talking to one another about why are we doing this when our colleagues in another state are not? 's >> and can all of you talked about comparative effectiveness studies. those studies could inform three different groups. they could inform your single-payer. they could import.or is or they can inform consumers. where do you think they are likely to have the most, john? 's >> i think it will ultimately have to be physicians. but i also think that there doesn't have to be the sense that physicians are working together in deciding what's best for their patients, even when comparative effectiveness studies come along, which are quite definitive for example a recent one showing not the tigre posse which is a final procedure has on average no good effects that the boston globe went to interview a physician who said i worship at the altar of

comparative effectiveness but i do a lot of these and my patients seem to do pretty well with them. so i'm going to keep doing it. so there's this total disconnect. i think hubble.surgeon changes behavior, him, it's not a herd and i think the answer that if they realize together this group of patients are providing funds butch's ltd., which is not before service where you can't keep spending and spending. >> their pay is not dependent on how many surgeries. >> at that point the internal medicine physicians will start putting pressure on them and say look, are you really sure you're getting better results? can she do this better or ultimately hire somebody else. >> the straightforward way to go would be to give the cms that power to say we're not going to pay for this event doesn't meet our tests. congress has been very unwilling

to give that power. and even in the language in the house and senate bill that stranger promotes comparative effectiveness research the next section says were going to do all this research but it can be used. >> because that smells of a government agency rationing care. >> having medicare could try to do that but it would be a disaster because the depositions telling their patients -- >> you need this and i want to do this but the government while at me. >> you could imagine not zero maybe 30% co-pay or something like that. even mary think the more effective mechanism is basically the other positions kind of sit down with this spine surgeon and say we can't afford you. you either change your practice or you go someplace else. >> able to respond to the senate. when you're dealing with the matter of life and death making an economic decision is pretty difficult, but i think all of us have probably been in the situation where the size of the

co-pay on a drug that we've been prescribed may determine whether we get the generic or the brand name. >> i agree with john that the incentives are probably more effect you that the position level than the patient. want to come in and you're sick and you're not able to make this rational cost effectiveness calculus, but we haven't really been given position very big economic you can't has to in a way that we're talking about here. there's something called paper for poor man's were you give physicians think that him into the medical guidelines. the incentives tends to be pretty small and also it's not clear whether we are rewarding better quality, maybe just more services. we have a user research evidence enough to do try to tailor economic incentives to make it really worthwhile for physicians to follow the practice guidelines. >> the other thing i think is very unfortunate in this

emerging debate about evidence is there really has been framed almost entirely in terms of controlling costs. and that's important, but there's another side of it which is improving quality. i don't want to go to the doctor and have a problem and the doctor not know what the best remedies for me. i don't want my children, my wife, i want the best possible medicine. and the reality today is my doctor may not know because the studies have been done. and so trying to frame this as a quality improvement or shouldn't every american be entitled to get the never have the best available science behind their treatments? i would be more positive frame and it's really not been pushed in that direction. >> if nothing else happened, john, and you voiceprint compared evidence of effectiveness studies done by the government that clearly publicized how much would a difference that make? 's >> not as much as he might think. i mean, you really have to get -- ask an economist. ucla would take away my degree if i sat incentives really

matter. [laughter] >> eric come you didn't answer the questions that let me ask you now. what do you think of the bills that are being considered by the house and the senate? how far did they go in dealing with the problem in your view? 's >> they don't go very far at all in terms of cost control. there's an interesting and promising ideas at the private level. the past history suggests that most of those pilot ideas will not be taken up. they will not be institutionalized. the thing it gives me some hope is unfortunately what john skinner was talking about is this is going to be pressure on the tax side to face some hard choices. and unfortunately that is the mechanism that is going to pressurize to face up to these health care costs. >> it's an interesting thing about pilots that i find similar in education, another area where the market forces -- with a

market system doesn't really work. you up all sorts of great pilot projects that people can point to going on all over the country saying wow, that's really great, it really works but they don't get the air. there's no best practice process, no incentive for other people to do with the best people are doing. why is that? >> well, i think for institutions to try to adopt best practice they take a big hit in terms that they actually lose money for medicare if they keep their patients out of the hospital. and so a terrific article -- the >> it doesn't pay to be best practice. >> there's a terrific article in "the new york times" about a doctor named brent james in salt lake city who was experimenting with these things and trying to get best practice in measuring, measuring, measuring outcomes. indeed knowledge is that we take a hit financially, but this is the right thing to do to provide

the best quality care we can. there aren't that many people who either -- who can manage to do that. >> time coming your analysis of why you thought the health care bill was the right thing to do i thought was very interesting because it mirrors what i hear some of the proponents and some of the opponents say about the bill, which is that you think it will take us down a step towards where you think we need to go, which is some sort of single-payer or single-payer monopolistic buyer system. am i interpreting correct? >> no, not quite. i don't think that this will necessarily bring us there, particularly since the public option doesn't seem to be a big part of it. the reason i like the bill is two things and i will give us universal coverage and will require insurance companies to take all coverage in charge than the same amount. so i think it's important to get

universal coverage and to get rid of insurers charging sicker people more than i think that's what we need to get legislation and then i think we can learn about the cost containment. i'm skeptical about being able to use the leverage purchases the way other countries do and still would like to see this passed. >> john, you made a compelling argument that is health care costs go up, inevitably taxes will go up. and as taxes go up, we will get health care costs under control. you didn't really tell us how that's going to happen. it's a historical fact in other countries, but what the mechanism? >> we have a specialist here. >> one thing i think is fascinating is the tremendous stability in the political acceptability of taxes in the united states before this economic downturn, since the

50's, we really have only taxed at the federal level about 18.5% of gdp. and we've kept that since the korean war with added medicare, medicaid, great society, social security, and despite all the new government we tried to keep taxes fairly level. yeah, it's gone up and down with democrats and republicans but we've not done is say we the american people want a bigger government and more taxpayers because were adding all these programs. >> aren't we inevitably headed towards 30%? >> i have not seen the willingness to raise to that level in either party. >> okay, let's put taxes aside for a second and talk about spending because spending has been slightly higher but say around 20% of gdp. do any of you see any way that we're not going to find ourselves 20 years from now at something closer to 30% gdp? 's >> sure if were spending that much, it's going to be cutting out other things that can be

spending and at some point americans buy enough unacceptable. so how do we try to control health care spending. well, we were pledged successful in the mid-late 90's for very strict managed-care. there was a minister but through accountable care organization that john is talking about that i provide a mechanism and allow us to manage care better. one way we manage premiums they charge people a high deductible. there are lots of ways that we can try to get health care costs that are under control. there has to be able to do it and if it's crowding out other things that we once more, that probably won't work. >> the prediction, 20 years from now, federal government spending as a% of gdp, best guess what would it be? 's >> where are now?

24.6%. >> i think it's going to be between 20% and 30%. >> because public pressure will force it down one way or another. >> i think we should open it up to questions in just a minute if you have a question, make your way to the back. i want to ask one of the things based on eric's numbers while people are assembling back there. the difference between republican and democrats is pretty straightforward. republicans tend to have less faith in government, more faith in individuals. but how do you explain the senior citizen number? these are people who are already in a government run them and you probably have the most familiar rarity with the health care system in our society. >> i think many people don't think they are in a government program. i think many people in the league that medicare they see their own doctors and have a lot of choice, darren medicare

advantage, a private program. they don't see themselves as recipients directly. >> how could that be? [laughter] >> well, i mean, when the medicare program we set up was designed deliberately in many ways to try to preserve the physician not funny, professional autonomy of physician and people do it that way. >> that's fascinating. anyone want to add to that? >> it is a wonder. >> go ahead. >> no mention has been made of the employer employee relationship and so much of our medical cost of the employee having an exclusion of the income of the cost of plans paid by the employer. now, at one time these costs

paid by the employer were taxed. during world war ii, when there was waged price control and a shortage of labor great pressure was put onto the revenue service to come out with the ruling, which excluded this financially. which was rather strange because if the employer paid for your food very basically your clothing, that would all be taxable. but health care was taken out as a way of really attracting more labor back to the market. now, what do you think the impact on cost would be if congress reversed the situation?

[laughter] >> so what you do think about that? you know, senator mccain when he ran for president was calling for that. and a lot of discussion about the cadillac plans. >> yup. >> why not at least tax the difference between the chevrolet and cadillac? >> it seems a fundamental issue of fairness. i totally agree with you on the cadillac plan. that is provide a fixed dollar amount, even a tax credit for

plans to really get the revenue. to really dig in and get more of that revenue. and just basically say to firms, you are on your own. this is not tax deductible at all. i think you would end up being criticized. you are trying to keep the balancing act where firms continue to provide health insurance. if you don't give them the benefit, many more would say fine. you'd sudden find basically perhaps not a desure but a defacto public plan because so many employees would be dropped into whatever kind of options are out there to help pay for their plans. i think that's the balancing act they are following. i'm a big proponent of the so-called cadillac tax. >> i'm curious whether when your irs commissioner, you also tried to get rid of the tax deductions for home interest, mortgage

interest. >> the special -- internal revenue service and the congress. all of this is in the statute, in the code. internal revenue code. one of the things i had to commit to is that i would really follow the law. [laughter] >> the -- one reason i've mixed feeling about your proposal, one reason i favor is it is the current system of making the employer contribution to employee health benefits tax deductible is that it's very regressive. it really favors wealthier people. because they are more likely to have health insurance, they are more likely to comprehensive policies, and they also have higher marginal tax rates. it really is a very unfair system that we have right now. just as deductibility of the home interest is already regressive system as well when

we don't give that to the renters. i do think there'll be some mild savings. i think there'll be tremendous political opposition. ellen suggested this now, gosh, almost 30 years ago. you take the money, and then you give everybody a tax credit of the same amount to make it -- to make it fairer. that seems like a reasonable way to go to me. >> cain johnson, years ago when hmos were first introduced into the system, they were thought to be able to solve some of the incentive problems that have been discussed this morning. they would bring into the organization of hmo issues associated with overuse of technology that wasn't really effective, the billing would be different and the physicians would see the tradeoffs because they were sharing in the pot of money that was being paid. is there any evidence that hmos did this? is there any proof that sort of

the incentive question can be managed? and we've got some experiences? it doesn't seem as if hmos are widely lauded as having changed things fundamentally. >> i can -- i'll start off here. in the beginning, it appeared that there was something great going on with hmos. there was when there was group and staff model hmo. where you went to the building and hospital that was hmo. turns out the marketplace didn't favor those. all of the group happened in ipa, independent practice association, i think it stands for. hmos without walls. where you are going to a doctor, but they are paid in a different way for the fee-for-service patient. you are going to the doctor. some are hmo, some weren't. there's no corporate culture to

control cost. people seem to favor that, and relatively few people stayed with kaye where are. they are not the types that have the culture. if you look at rates with increase with health care cost, hmos haven't done better than fee-for-service medicine. their enrollment is declined, ppos give them more flexibility. i agree with you, i think the model that worked is a model that is not very popular among americans. and kaizer is popular in california. >> i can follow up, kaizer grows at the same rate in other places. but it's consistently lower. that's the staff model where physicians are on salary. during the 1990s, they tried to expand. they were contracting with

private physicians. they were negotiating on price. so what the physician did more things, they would get paid more money. they it'll didn't really get, they did not scale up. there wasn't sort of the fundamental sent of incentives. so they never really worked particularly well. it is a little bit of a mystery why kaizerlike programs haven't overtaken and kept across the considerate. i think it's because often they not are paid that much more, relative to fee-for-service physicians. they can typically make more money. but also i think it's the perception of once you're in there, you don't get the same kind of choice. the idea behind is that if you would stick with your own doctor, they would be organizized more sort of in a

default capitation structure where they are paid on the basis of the patient of the number of patients in their practice. but they would still see the same doctors and go to the same hospitals. >> good morning, my name is ann. i've been a very grateful recipient of medicare for six years. fortunately, i have not have h to call upon it very much. this is a form of socialized medicine. that is not a dirty word. nor is helping our vets. that is socialized medicine. medicaid is also socialized medicine. the point i would like to make, and i'm -- and i believe in complete agreement with our first speaker. i was a very, very ignorant about the rest of the world's industrialized countries at least, and what they offer their

citizens. and yes, i do have a question. i've recently learned much. and i'm very, very grateful. i wish everybody had read the book that i'm currently reading. >> what, the book? >> i'm proclaiming ignorance it's sitting on my kitchen table. i read it with breakfast. >> is that the book we t.r. reid, where he has shoulder pain? >> absolutely. it is a book that now read by every american. however, what i saw is two very evident different in our country than those other countries. including taiwan which has a wonderful medical system. is that when our doctors, i am not a physicians, come out of medical school they have a tremendous amount of debt for the most part. unless they come from an extremely wealthy family. plus they are malpractice cost

are sos astronomically different. in some countries, i don't know if they have malpractice. we pay far more than any other country in the world. i don't know why. but perhaps you can address that. my question is: and i do have a question. do you feel that lobbyist, fortunately they weren't so strong when medicare came into being, are influencing congress, whether it be from the ama and i understand with this incredible malpractice, and our pharmaceutical companies? are they much more influential than intelligent information that our congressman are not receiving as mr. reid's book? >> who wants to take that on.

of course lobbyist are of tremendous influence. it's inevitable. in many ways it's beneficials that groups are going to organize. what i think is remarkable is the issues that have actually gotten on the agenda. people like peter orszag understands the issue. it's gotten there in part like researchers have pointed out these amazing patterns that no one can really understand that we're spending a lot more than some parts. and people don't seem to being any healthier. something weird is going on there. you can have lobbying pressure, you can have organizized groups, you can have voters. but when a problem exist that is

so stark and even people are pointing, eventually, it does change. i think it around health care has changed. a couple of years ago, i had the privilege of giving a talk about some of the research early. i talked about the need for more evidence and some of the problems. it was a fun talk for me, but also a challenging talk. but a lot of the people in the room haven't heard about this issue. had no awareness that the medical was a problem. there are a lot of physicians that were resistant. i think that's changed. there's been among the well-educated public a recognition that this is a problem. where we have a hard time is going from agenda fedding to actually solving the problem. because if the solution stage, what the laws are actually written. that's where lobby's have the most influence. that's very hard to overcome. >> again, i'm a member here at the miller center and at the bath ton -- baton school.

i wanted to mention the follow up on the nonprofit plans. the other aspect is mention for the medicare buy-in for 55 through 64. for about the last ten years although medicare cost growth is unsustainable, it's actually been lower than the overall health care system. i'm curious about the panel's view of the buy-in for cost control particularly in light of the roles for the public option. and of course it is the question of strong public option versus the public option that we had. secondedly, a follow up on a point, on the world employers and all of this. given the long-term unsustainability of the health cost in the united states, i'm curious of the panel's views on why employers have been resistance or at least there's

been mixed, at best mixed support for reform in general. i'm curious whether that itself is something that relates to issue of ideology or aspects of technical dimensions of reformed preferences. thanks. >> okay. i think we all probably have opinions about the medicare buy-in. this kind of hit me by surprise when it ended up being in the newspapers a couple of days ago. i think medicare is an effective program. i like the idea of more people being able a to buy into medicare. it certainly fits into my belief that power in the buyer side is an effective way to control health care cost. but of course the opposition that we are seeing is just because of that power. what we are seeing is the rural states are very much against this. because they are saying the hospitals aren't paid enough. by medicare, since medicare pays less, they'll get less money.

it's also slippery slope. i think there's a concern that it could mor much into a signal. it's natural. i think medicare have been an very effective influence program. i like the idea of more people being able to take advantage of it. i don't think this is going anywhere. they drop -- they planted this idea. it's just -- there seems to be too much opposition. i don't think it's going to be in the final compromise. but we'll see. with regard to the employees, they favored the clinton bill, then they changed their mind about it. you mentioned ideology, the best answer that i have is entrepreneurs don't generally tend to like the idea of government involvement in anything.

on the surface, you think they'd like to get out. >> i can tell you we do a meeting once a year, 100 ceos, large companies, different industries. we had a group of them in washington a month ago. two things were clear. there was enormous efforts to reduce health care cost. many of them had served on various panels for the business round table et cetera. a number of them had been in to meet with the president, with the secretary of health and human services. to a person, they felt like the legislation itself. they were pretty much programs. i gather from what the three of you said that you wouldn't disagree with that. >> well, it's a building block. it's getting things started. >> it's a hopeful approach. i mean i think there are some. aa side from putting every doctor on salary in the united states and sort of overnight

switching to an english system, i think it has to be evolutionary process. at least there seems to be recognition that incentives matter of the current fee-for-service system doesn't seem to be working very well. that's sort of the promising thing. it's a first step. i think agree with tom, i think covering the uninsured and it's kind of the first step. this is health care reform is going to be on the ape agenda for at least the next decade. so i don't see it like happening once and then stopping. >> i should say one of the worrying things is when president obama said other presidents have tried to reform health care but he hopes to be the last one to do it. that's a promise that's not going to be kept. no matter where it is. we are going to be modifying and tinkering with our health care system for many, many years. >> particularly if there is a bill, it looks like it's going to be passed on the party-line

vote. actually one thing you should never do is let go of the microphone. he's got it and he's holding on to it. it's going to be have to be very quick. >> poor alan, i take your point on. do they honestly believe though that they can deal with cost control within the current system if you don't take the first step? >> no. no. i think there's huge frustration. >> hi, i'm ed quinn. my dad is one of the cardiologist who's bankrupting america right now. he had a practice in las vegas, nevada. which is where i live. he moved to arizona once malpractice insurance reached six figures. he's currently being audited. he has to go back, he and my mom who handles the insurance part of the business have to go back and look up four to five years and check every single procedure to see if it was warranted or not. so now he and other doctors are

at the point where they are spending time excessively recording their dictations and documents what they've done in order to avoid getting sued and having money taken back from them. i will not be going into medicine, my dad has discouraged me. he said if i wanted to, i should do plastic surgery. there's no insurance companies and there's only cash. what incentives do people my age and younger in going into the medical field as opposed to business or law? and if the best and brightest decide not to go into medicine, what does the medical system have in the future? >> go into finance; right. first of all, i think with regard to malpractice, there was an earlier question about it. most of the key evidence suggest that most contributes about $60 billion per year in spending. which a whole lot of money. but relative to the $2.2

trillion it's relatively small. i think that we need malpractice reform. not because it's going to save money, al a though it may well. but simply because i think we are exacting a terrible toll on physicians every day when they go into work. because they don't know where today is the day that are going to get sued for something they might not have caused. often times if somebody happens, thing that is are bad do happen in health care because that's the way the human body is. they will get sued as a consequence. the jury will take pity on the poor individual and award loss of money to them. and the impliations is that the physician did something wrong. where they may or may not have done something wrong. i think that one of the real interesting political puzzles is why malpractice reform isn't on the table as a way to get the republican side of the -- of

congress on board. and physicians, and the ama on board. and it seems like that's not happening. it's partisan politics and i think it's bad partisan politics. i too find it puzzling. >> what parts of politics because trial lawyers are such loyal supporters of democrats. >> we did ask one question about malpractice. it's clear the public is worried about the combination of the current system and having more studies. 78% of the public that we interviewed agree that doctors who are worried about malpractice may follow the results of the studies even if they think another treatment option is better for their patients. once the studies are there, the doctors are going to have to follow them or they will be sued even if they believe another treatment is better. >> i'm sorry, we're going to have to limit it to one more

question. >> yes, as the german system, i'm president castro from the german system of finance. also as some of you, you feel the german system is a complete mess. it is a two-tear system. it is for those that we have salary levels. it's private insurance. below that public insurance, it is called insurance system, but nevertheless, policy driven. this is paid out by payroll contributions, and it is paid out by state subsidies. so it may be right that there is the kind of monoops, but we still have the feeling that we pay for pharmaceutical, for instance, much more than in italy. also in the public system, there is a big, big disincentives. for economics, always doing good incentives. so we also rethinking it.

they never worked out. the people getting more and more annoyed with all of this stuff. what about a system? setting say maybe a mixed system between a public system and private system? maybe you have a public system at the bottom, also covering a kind of public good which is in good health services, paid out of taxes or paid contribution with the right set of incentives. keeping the good, getting rid of the bad. maybe on top the public system for everybody then on top based on say risk aversion or not, paid by private -- with private insurance companies who buy packages whatever you like. so this could be a system. so there is no competing with public and private if the incentives set right. may be both work together. if you are following the u.s. discussion, you are surprised about the views here. maybe we can draw off of some experience from the public

system. >> is what -- is the danger there that the healthy people opt out of the healthy and move into private or what? >> the danger is that it would become like medicaid. fewer people seem to be proposing that we move medicaid up than we move medicare down. because, you know, the political will to maintain medicare is because all people over age 65, many of whom vote, are in favor of medicare. whereas medicaid is for a group where there are probably fewer voters. and i think that's one consequence why medicaid payments have lag far behind even medicare. >> i kind of like the mixture having german. germany is so critical of their system. they have a good system. they have engaged in con restaurant reform.

i think they made it better. it was a good system. it's still good. the mix that you have now is 10% buying private insurance to 10% of the most wealthy people. 90% who are in the public system. that actually is a very nice match. in the u.s. where we have -- you know, i don't know 20% of the people on medicaid, although it pays for the 40% of the births, there's just not even public support to sustain that at a good enough quality. but 90% of the public system, 10% of the private system, that works for me. >> you have a very brief follow up. >> very brief went to eric. i was surprised that a lot of the americans believed that doctors can do everything? have you ever checked this against a sample of doctors? >> that's next. >> thank you. thanks very much. [cheers and applause] >> thank you, panel. we're going to take a 15-minute

break and reconvene to talk about making policy. >> president obama met with national security officials today at the white house about the december 25th attempted airline bombing. afterwards, the president spoke to reports. we'll have the president's remarks tonight at 8:00 eastern on c-span. a number of economist participated in a discussion this morning on the state of the world economy. they talked about how different nations have weathered the recession and prospects for improvement. carnegie endowment hosted this event. >> good morning. my name is pieter.

i'm also a nonresidence caller here in carnegie institute. this is the first seminar of the year, i understand. and the title of the seminar appropriately is happy new year, the world economy in 2010. but there is a question mark behind the happy new year. the meaning will become clear in the proceedings during the seminar. the recession that we are struggling to get out of is in a usual recession. and that is the reason for the question mark behind the happy new year. we have five panelist. all make it their business to predict the future, but at least trends in the future. and they have heavy hitters in that subject. all of the man here, dadush is

the director of the international economic program here at dadush. he worked a long time where he was responsible for research and trade policies and for the publication of the very influential global economic outlook publication. next to him, they have phillip suttle who is the global hat of economic research at the institute of national economics here in washington. he is responsible for developing ifis economic work to brood microeconomic views and product development. he is the author of many long and sort articles that are published in vary ways, including on the web. next to me on the left is uri who is the head of the world

economic studies division in the research department of the imf. he coordinates the imf world economic outlook and he has let the imfs eu's policy division and the division to israel. he has on capital market and reform and stability and european growth. he is also the author of a recent book, integrating europe's financial markets. on my immediate right is mr. blackman, currently after he served as manager director and chief emerging market and chief strategist. he was also prior to that, the deputy director of the i